心血管系统疾病先心病动脉导管未闭课件

动脉导管未闭 Patent Ductus Arteriosus 动脉导管未闭 Patent Ductus Arteriosus, PDA Main contents n Prevalence 流行病学资料 n Pathological anatomy 病理解剖 n Physiology & hemodynamic changes 病理生理及血流动力学改变 n Clinical Manifestations 临床表现 n Specific studies 特殊检查 n Electrocardiography 心电图 n Chest X-ray X光胸片 n Echocardiography 超声心动图 n Cardiac catheterization and angiography 心导管及心血管造影 n Complications 并发症 n Management 治疗 发病率及自然闭合率 Incidence and the rate of nature closure n 动脉导管未闭(PDA)是小儿时期常见的先心病， 其发生率约占先心病的15左右 n 动脉导管于出生后1015小时内在功能上关闭， 生后3个月左右在解剖上关闭 n 若持续开放，并产生病理生理改变，即称为PDA 病理解剖 Anatomic Pathology 动脉导管位于肺动脉与左锁骨下动脉开口远端的降主 动脉处，按其形态可分为5型：管型、漏斗型、窗型 、动脉瘤型及哑铃型，以前3种类型较多见 直径多为 0.51cm，长为0.71cm 病理生理及血液动力学改变 Pathophysiology n 分流量大小与下列因素有关： n 导管直径 n 主、肺动脉之间的压力阶差 n 肺血管阻力 Pathophysiology 右心房 右心室 左心房 左心室 扩大 扩大、肥大 肺动脉 主动脉 体循环 血容量减少PDA分流 周围动脉 舒张压力下降 脉压增宽 肺动脉循环 血流量增加 临床表现 Clinical Manifestations 临床表现主要取决于分流量的大小 n 症状 Symptoms n 小型导管，导管细，分流量小，多无症状 n 中到大型导管，症状出现早且重，多于生后6个 月即可出现呼吸增快，易乏力，活动后心悸、气 喘、咳嗽等 n 粗大型导管，分流量很大，婴儿早期即出现严 重症状，反复呼吸道感染和肺炎以及心功能不全 等 临床表现 Clinical Manifestations n 体征 Signs n 一般体征 中等导管以上患儿多消瘦、胸廓畸形 。如因肺动脉高压而有右向左分流时，下肢可出现 发绀、杵状趾等（差异性青紫） n 心脏体征 不同程度的左心扩大 典型的体征是于胸骨左缘第二肋间听到 粗糙、响亮的机械样连续性杂音 杂音向左锁骨下及颈、背部传导 最响处可扪及震颤 典型的心脏体征 望诊：心前区隆起 触诊：双期震颤 典型的心脏体征 叩诊：心浊音界向左扩大 听诊：L2 粗糙、响亮的机械样 连续性杂音 P2 增强或亢进 临床表现 Clinical Manifestations n体格检查 n 周围血管征 因体循环舒张压降低，故脉压差增 大，并可能出现类似主动脉瓣关闭不全的周围血管 体征 水冲脉 毛细血管搏动征 周围大动脉枪击声 舒张压降低，脉压差增大 水冲脉 毛细血管搏动征 周围大动脉枪击声 心电图 分流量较大者可出现左心室肥大 辅助检查 Specific studies n 分流量小 X线检查可无异常 n 分流量较大 X线示左心房及双心室增大，以左心 室扩大为主，肺动脉段突出，肺门血管阴影增粗， 肺野充血，透视下可见搏动，主动脉增宽，主动脉 弓扩大 n 分流量大并有肺动脉高压者 显示双心室增大， 右心室扩大更为明显，肺动脉段突出明显，周围血 管影变细，此时，肺野充血反不明显，似枯树枝或 截枝状 X光胸片 Chest Radiography 辅助检查 Specific studies n M型超声：显示左心室、左心房增大，主动脉前 后径增大，左心室后壁与室间隔活动幅度增加 n 二维超声：心底部短轴可直接显示肺动脉主干 与降主动脉间未闭的动脉导管 n 彩色多普勒：胸骨旁大动脉短轴切面，可观察 到一红色或伪彩色镶嵌状射流由降主动脉经未闭的 动脉导管进入主肺动脉 超声心动图 Echocardiograph 辅助检查 Specific studies n 右心导管检查主要发现： n 异常途径：导管可由肺动脉经未闭的动脉导管 进入降主动脉 n 血氧资料：肺动脉平均血氧含量比右心室高， 提示肺动脉水平存在左向右分流 n 压力资料：监测肺动脉压力和肺小动脉嵌顿压 ，并计算出肺总阻力和肺小动脉阻力 心导管及造影 Cardiac Catheterization 辅助检查 Specific studies 心导管及造影 Cardiac Catheterization n 逆行主动脉造影检查 经导管注入造影剂时，可见升 主动脉和主动脉弓扩大，肺动脉同时显影，可见未闭 的动脉导管显影，可测量导管的直径、长度和形态 并发症 Complications 肺炎 pneumonia 心力衰竭 heart failure 或肺水肿 pulmonary edema 肺动脉高压 pulmonary hypertension 细菌性心内膜炎 bacterial endocarditis 治疗 Treatment n 内科治疗 PDA患儿有并发症者，一般应先进行内科治疗， 感染控制后再行介入或手术治疗 治疗 Treatment n 介入性心导管疗法经心导管PDA闭合术 近年来，心导管治疗PDA已成为PDA治疗的首选。 主要有两种方法： n Coil弹簧圈堵塞法：除窗型以外的各型左向右 分流的PDA，尤其管径2.5mm者；任何年龄 n Amplatzer 蘑菇伞堵塞法：除窗型以外的各型 左向右分流的PDA，管径为2.58mm者；体重 4kg 治疗 Treatment n 手术治疗 目前大多数PDA可通过非开胸介入性心导管疗法堵 塞，故手术治疗主要适应于 n 导管较粗或窗型 n 合并ASD或VSD，多需矫正其他畸形者 n 无经济条件作介入治疗 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