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房间隔缺损室间隔缺损课件_1

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室间隔缺损课件 室间隔缺损ppt 房间隔缺损PPT 房间隔缺损房间隔缺损
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*1 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 l先天性心脏病 Congenital Heart Disease With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 主要内容 l正常胎儿循环的特点及生后血液循环的变化 l儿童心血管病检查方法 l先天性心脏病概述 l常见先天性心脏病:房间隔缺损、室间 隔缺损、动脉导管未闭、法乐四联症 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 目的要求 l1.一般了解小儿循环系统解剖生理特点 l2.熟悉先天性心脏病的病因、分类及各类 型特点(重点) l3.熟悉先天性心脏病的诊断方法 l4.熟悉先天性心脏病的治疗原则 l5.掌握四种常见的先心病的临床特点(重点) 和诊断要点(重点)、病理解剖、血流动力学 变化(重点) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l正常胎儿循环的特点及生后血液循环的变化 l儿童心血管病检查方法 l先天性心脏病概述 l常见先天性心脏病:房间隔缺损、室间隔缺 损、动脉导管未闭、法乐四联症 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 正 常 胎 儿 循 环 特 点 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 脐 静 下 右 卵 左 V 脉 腔 心 圆 心 导 V 房 孔 房 管 右 左心室 胎 心 盘 室 主动脉弓 肺动脉 肺 肺静脉 头、颈、上肢 80% 脐 盆腔 降主A 动脉导管 上腔V A 下肢 正常胎儿循环的特点箭头图 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 正常胎儿循环的特点 l胎儿时期的营养和气体代谢是通过 母体实现的 l胎儿体内是混合血,脑、心、肝及上 肢的血氧含量高于下半身 l卵圆孔和动脉导管是开放的 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 生后血液循环的改变之一 :卵圆孔关闭 生后呼吸建立 肺循环压力下降 右房﹤ ﹤ 左房压力 肺血流量增加 压迫卵圆孔瓣(第一房 间隔)紧贴第二房间隔 卵圆孔关闭 (5~7个月) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 生后血液循环的改变之二:动脉导管关闭 自主呼吸建立 血氧升高 动脉导管平滑肌收缩 肺循环阻力降低 动脉导管处 动脉导管 体循环阻力升高 血流逆转为 关闭 左向右分流 (80%3个月、 95%1年内) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l正常胎儿循环的特点 l儿童心血管病检查方法 l先天性心脏病概述 l常见先天性心脏病:房间隔缺损、室间隔缺 损、动脉导管未闭、法乐四联症 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 儿童心血管病检查方法 l病史:心脏杂音、青紫、心功能 不全、声嘶。 l体检:全身检查(生长发育、呼 吸频率、紫绀、杵状指趾) 及心脏检查(视触叩听)、 周围血管征。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 儿童心血管病检查方法 l特殊检查: 1.普通X线检查:胸片 2.心电图 3.超声心动图:M型超声心动图、多 普勒超声、二维超声心动图、三 维超声心动图 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 儿童心血管病检查方法 4.心导管检查 5.心血管造影 6.放射性核素心血管造影 7.磁共振成像 8.计算机断层扫描 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l正常胎儿循环的特点 l儿童心血管病检查方法 l先天性心脏病概述 l常见先天性心脏病:房间隔缺损、室间隔缺 损、动脉导管未闭、法乐四联症 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l先天性心脏病(Congenital Heart Disease,CHD)是胎儿时期心脏及大血 管发育异常所致的先天性畸形,是小儿 时期最常见的心脏病。其发病率约占活 产婴儿的6~10‰。 先天性心脏病概述先天性心脏病概述 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 随着科学技术的不断发展,先天性 心脏病的介入治疗、心脏外科体外循环 及深低温麻醉下心内直视手术的发展, 使大多数先心病根治手术的效果大为提 高,新生儿期复杂心脏畸形手术成功率 不断提高,先心病的预后已大为改观。 先天性心脏病概述先天性心脏病概述 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病因: 遗传、母体、环境 l遗传因素:染色体异常或多基因突变 l母体因素:感染和疾病,风疹、流感、 腮腺炎及柯萨奇病毒感染等;代谢性 疾病如糖尿病、高钙血症、苯丙酮尿 症等,其他:如物质缺乏如叶酸,宫 内缺氧,有害物质放射线,药物如抗癌 药、抗癫痫药, l环境因素: With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 预防 l加强孕妇保健:早期补充适量叶酸 l避免接触药物、辐射等高危因素 l预防风疹、流感等病毒性疾病 l积极治疗相关疾病:如糖尿病、高钙尿症 l及时发现宫内缺氧 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 分类 l左向右分流型(潜伏青紫型)房间隔 缺损、室间隔缺损、动脉导管未闭等 l右向左分流型(青紫型)法洛四联症 、大动脉转位等 l无分流型(无青紫型)肺动脉狭窄和 主动脉缩窄 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l正常胎儿循环的特点 l儿童心血管病检查方法 l先天性心脏病概述 l临床常见先天性心脏病:房间隔缺损、室间 隔缺损、动脉导管未闭、法乐四联症 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床常见的先心病 l房间隔缺损 Atrial septal defect (ASD) l室间隔缺损 Ventricular septal defect (VSD) l动脉导管未闭 Patent ductus arteriosus (PDA) l法洛四联症 Tetralogy of Fallot (TOF) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房间隔缺损 l房间隔缺损(Atrial septal defect , ASD)是 小儿时期常见的先心病,其发病率约 为活产婴儿的1/1500,占先心病发病 总数的5~10%,男女之比为 1:2,且有 家族遗传倾向。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society PV LA PA LV PV SVC RA AO IVC RV 肺静脉 肺静脉 上腔静脉 右心房 主动脉 下腔静脉 右心室 左心房 脉肺动 左心室 房间隔缺损 血流动力学示意图 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 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) 肺血流量明显增加(肺充血) 肺小动脉痉挛、增厚 体循环供血不足 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 ASD 血流动力学变化 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 血流动力学改变 l暂时性右向左 l肺循环增多 l体循环减少 l右心负荷异常 l肺动脉高压 l艾森门格综合征 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l小型:无症状,仅有杂音. l中大型: 体循环血流量不足:乏力、多汗、 活动后气促、吃奶中断、发育落后 l肺循环血流量增多:反复呼吸道感染、 充血性心力衰竭、声嘶;晚期:右向左 分流,青紫、艾森门格综合征 临床表现临床表现——症状症状 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l艾森门格综合征:随着肺血管病变的进行 性发展,容量性肺动脉高压渐变为不可逆 的阻力性肺动脉高压,当右心室收缩压高 于左心室收缩压时,左向右分流逆转为双 向分流或右向左分流,出现发绀,即艾森 门格综合征。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现—体征 l心前区隆起,收缩期抬举感;S1亢进; P2 增强,固定分裂; L2~3肋间闻及2~3/6级 收缩期喷射性杂音;当肺循环血流量超 过体循环1倍以上时,三尖瓣区可闻短促 、低频的舒张早中期杂音(三尖瓣相对 狭窄)。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现—体征 l随肺动脉高压进展及左向右分流减少 ,P2增强,固定分裂消失,L2~3收缩期杂 音缩短,三尖瓣舒张期杂音消失,可出 现肺动脉瓣及三尖瓣关闭不全的杂音 。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 特殊检查 lX线表现:心影增大,呈 梨形,以右房、右室为 主,心胸比例〉0.5,肺 动脉段突出及肺血管影 增多,主动脉影缩小 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l心电图 电轴右偏 右房、右室肥大 V1、V3R rSr’或 rsR’等不完右 P-R延长交界性心律或室上性 心律失常 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l超声心动图 右房、右室增大 主肺动脉增宽 ASD部位和大小 分流方向、分流量 RV 收缩压及PA 压力。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l磁共振成像 ASD部位、大小及其肺静脉回 流情况 l心导管检查 测LA、RA 及腔静脉血氧含量 ,RV、PA 压,计算PA 阻力和分流量 l心血管造影 造影剂 右上肺静脉 LA RA With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 诊断及鉴别诊断 l根据病史、临床表现和X线胸片、心 电图、超声心动图(M 型、二维及 彩色多普勒)即可确诊 l应与肺静脉畸形引流、肺动脉瓣狭 窄及高位室间隔缺损。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房间隔缺损并发症 l支气管肺炎 l肺动脉高压 l房性心律失常 l肺动脉瓣、三尖瓣关闭不全 l充血性心力衰竭 l感染性心内膜炎 罕见 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 治 疗 l小型继发孔型 l ASD 在4岁内有15%的患儿自然闭合。 l最佳手术年龄学龄前期,目前有内科 介入封堵术和外科开胸手术两种治疗 方法 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房缺介入封堵术—适应症(1) l年龄大于2岁 l继发孔房缺,其局部解剖结构须满足以 下条件: a) 直径30mm b)边缘至少5mm c)房间隔的伸展径大于房 间隔缺损14—16mm With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房缺介入封堵术—适应症(2) l复杂先心病功能娇治术后遗留的房缺 l继发孔房缺经外科手术修补后残余分流或再通 l二尖瓣球囊扩张术后明显心房水平左向右分流 l临床有右心室容量负荷过重的表现,如右心室扩 大等 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房缺介入封堵术—禁忌症 l已有右向左分流者 l多发性房间隔缺损 l合关并有其它的先天性心血管畸形 l心脏内有血栓特别是左右心耳内 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房缺介入封堵术(1) l房缺介入治疗的基本原理是经导管在 房间隔缺损的部位送入一个双盘结构 的封闭器,双盘中的一个盘在左心房 而另一个在右心房 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房缺介入封堵术(2) l两个盘由一腰相连, 而该腰正好通过房间 隔缺损口,双盘夹住 房间隔,一方面关闭 房间隔缺损,另一方 面固定住封堵器。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 房缺介入封堵术—并发症 l残余分流,即封堵器未能完全覆盖缺损 口 l异位栓塞,为封堵器脱落引起的严重并 发症 l血管并发症及感染 l机械性溶血较少见 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床常见的先心病 l房间隔缺损 Atrial septal defect (ASD) l室间隔缺损 Ventricular septal defect (VSD) l动脉导管未闭 Patent ductus arteriosus (PDA) l法洛四联症 Tetralogy of Fallot (TOF) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 室间隔缺损 l室间隔缺损(Ventricular septal defect, VSD)是胚胎期心室间隔发育不全而形成 的左右心室间的异常交通,在心室水平 产生分流的先心病,约占先天性心脏病 的50%。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 室间隔缺损 血流动力学示意图 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 主动脉 左心室 VSD With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 上、下腔静脉血 肺静脉 右心房 左心房 右心室 (肥厚) 左心室 肺血流量明显增加(肺充血) 肺小动脉痉挛、增厚 体循环供血不足 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) VSD VSD 血流动力学变化 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 血流动力学改变 l肺循环增多 l左室容量负荷增大 l体循环减少 l肺动脉高压 l右室压力负荷增大 l艾森门格综合征. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现—症状 l小型VSD:可无症状,仅有杂音 l大缺损: 体循环流量不足:喂养困难、活动后气 促、多汗,生长发育落后 肺循血流量增多:反复呼吸道感染、充 血性心力衰竭、声嘶;晚期:右向左分流 ,青紫、艾森门格综合征。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现—体征 l心前区隆起;收缩期抬举感;P2增强,L3、 4肋间3~4/6级响亮而粗糙的全SM,常伴有震 颤;心尖区较柔和的DM l大型VSD伴明显肺动脉高压时,右室压力显 著升高,SM减弱或消失;P2显著亢进;继发 漏斗部肥厚时P2减弱。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 特殊检查 l心电图 正常或轻度左室肥大 RV5、V6升高伴深Q 波,T 波直 立高尖对称,以左心室肥厚为主 双室肥厚或右心室肥厚,左房扩 大,P波有切迹或增宽 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society X线: 小的VSD无异常。 大中型VSD心影增大,左房、 左、右心室增或双室大, PA 段延长或突出或扩张 肺血增多 艾森门格综合征时PA 主支 增粗,肺外周血管影很少。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society l超声心动图 小的VSD可无异常, LA、LV横径增大 室间隔回声中断 明确心室内分流 估测肺动脉压力 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 诊断及鉴别诊断 l典型的室缺根据病史、临床表现和X 线胸片、心电图、超声心动图(M 型、二维及彩色多普勒)即可确诊 l应与房缺、肺动脉瓣狭窄及PDA等鉴 别。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 室间隔缺损并发症 l反复呼吸道感染 l支气管肺炎 l肺动脉高压 l充血性心力衰竭 l肺水肿 l感染性心内膜炎 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 治疗 l自然闭合:20~50%膜周型及肌部 小梁部缺损可自然闭合,中小型 VSD可随访至学龄前 l对症治疗:呼吸道感染、心衰 l介入治疗和外科手术治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changi
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