【作者】 王爱云；

【导师】 王玉林；

【作者基本信息】 山东大学 ， 儿科心血管， 2010， 硕士

【摘要】 研究目的：观察胎儿单纯室间隔缺损的自然转归情况,并探讨影响单纯室间隔缺损自然愈合的部分相关因素。先天性心脏病(简称先心病)是小儿最常见的先天畸形,是由环境因素和遗传因素等共同作用所致的多基因遗传病,发生率约为0.6%-1.2%。据统计,我国先天性心脏病在正常人群中发病率文献报道大约为8‰,是新生儿最常见的先天性畸形,也是新生儿及婴儿的重要死亡原因。我国每年出生先天性心脏病患儿约15万,单纯性室间隔缺损是先心病中最常见类型,约占总数25～40%。缺损可发生在室间隔任何部位,如膜部、流出道、和肌部。部分病例可在宫内或出生后3年内,缺损逐渐变小或自然愈合。目前,国内外研究较多的是应用超声心动图筛查诊断胎儿期各类先天性心脏病以及如何提高诊断准确率。在Stiimpflem等的研究中强调了胎儿超声心动图在诊断心脏缺损与其他无法诊断的染色体畸变的重要性,敏感性88.5%,特异性100%先心病产前诊断的最终目的是改善胎儿预后。孕早期超声心动图发现胎儿心脏严重畸形后,优生性引产成为产科临床处理的选择之一。通过筛查,父母在产前被告知先心病的诊断、严重程度及预后情况,重症复杂畸形胎儿可及时终止妊娠。准确的产前检查结构有助于选择最佳分娩时间,对于早期救治新生儿、确立正确的先心病治疗方案有较好的指导意义。临床上还可确定产前及产后必要的护理,从而提高严重先心病婴儿的成活机会。超声心动图作为一种对胎儿及母体均无创伤的检查方法,Winsberg1972年首先报道利用M型超声测量胎儿心脏的结果。80年代初,Kleinmanji及Allan等相继建立胎儿超声心动图方法,开展了先心病产前诊断的研究。随着围产医学的迅速发展,胎儿超声心动图的应用,已能较准确地评价胎儿心脏结构和血液动力学的变化,可对大部分胎儿先天性心脏病作出产前诊断。胎儿超声心电图可无创伤性的探测胎儿各期的心腔和大血管的内径、心脏瓣膜活动、胎儿血流动力学及心脏活动节律等,不仅是早期诊断先心病的安全可靠的手段,更为进一步改善先心病的预后、提高新生儿生存率创造了良好的条件。大量的临床资料证明,先心病的产前监测会大大改善复杂先心病,特别是导管依赖型和心室、大血管严重发育不良的先心病所出现的严重紫绀和酸中毒。近年来国外已开展了先进的宫内介入手术治疗某些胎儿先心病,使得先心病的治疗有了更大的突破。为此,我们采用彩色多普勒超声诊断仪筛查胎龄在20～28周的孕妇。在心脏四腔切面、左室流出道及主动脉长轴切面等心脏多切面,观察室间隔是否有回声中断及穿隔血流。发现阳性患者,可指导临床对该患儿进行进一步检查,以除外合并其他畸形或染色体异常等疾病；并指导室间隔缺损患儿临床手术治疗时机,以及优生优育有重要意义。研究的方法：对于妊娠20周以上孕妇,向其讲明筛查胎儿先天性心脏病的必要性,以及目前经超声心动图能筛查诊断出的胎儿先心病种类,经同意后行胎儿心脏超声检查。孕妇仰卧位,选择胎儿心脏条件,探头置于母体腹壁滑动,首先确定胎位,纵切扫查胎儿脊柱,探头旋转90度,横切胎儿胸部获清晰心脏四腔观,在此切面通过二维观察心胸比例、房室腔大小及比例、二尖瓣、三尖瓣(位置、瓣膜发育、开放情况)、房间隔有无、卵圆孔大小、室间隔连续性及心室是否有占位性病变等,改变声束方向获得左室长轴切面、心底短轴切面、左室流出道、右室流出道及主动脉、肺动脉长轴等各切面,进一步观察胎儿心脏及大血管结构、形态；阳性病例分娩前(37.40周)复查一次,记录相同项目相关数据。产后一月内利用超声心动图复查新生儿心脏,对于未闭和的患儿,每六个月随访复查,随访3年。各组数据输入SPSS12.0统计软件,经软件处理,寻找相关因子及相关系数。胎儿确诊室间隔缺损后在分娩前复查一次。产后一个月内利用彩色多普勒超声诊断仪超声复检新生儿心脏,对于室间隔缺损未闭合的患儿,每六个月随访复查一次,连续随访3年。经两次彩色多普勒超声检查未发现房室分流者确认室间隔缺损愈合。利用计算机软件SPSS15.0进行单因素分析。研究结果：1.单纯室间隔缺损126例,其中分娩前缺损宫内自然愈合2例,分娩后完成随访86例。2. 86例中,手术治疗17例,生后室间隔缺损自然愈合55例,10例缺损随访3年仍未愈合,4例生后早期因不同并发症死亡。3. 55例中,12个月以内缺损自然愈合者28例,占49.1%,24个月缺损自然愈合52例,仅占91.2%,平均(13.7±8.5)月。4.自然愈合的高峰在24个月以内。5.缺损发生在室间隔肌部52例其中48例自然愈合,占92.3%,发生在室间隔上段14例其中9例自然愈合,占64.3%,且不同缺损部位自然愈合率经卡方检验证实存在显著差异(χ2=7.355,P=0.007<0.05)。6.影响室间隔缺损自然愈合时间的相关因素分析：3岁以内婴幼儿VSD的自然愈合时间各不相同,将其分为1～12个月、13～24个月和25～36个月三个阶段,研究VSD的缺损部位、大小和穿隔血流速度等与缺损愈合时间的关系。7.缺损部位与室间隔缺损愈合时间的关系：室间隔肌部缺损者,生前及生后0～12个月自然愈合的例数较多,为26例(占54.2%),而室间隔上段缺损者在生后13～24个月自然愈合的例数较多,为7例(占77.8%),但不同部位的缺损在不同时间段的自然愈合率无显著差异(χ2=5.742,P=0.057)。8.室间隔缺损大小、左-右分流及右-左分流速度与室间隔缺损自然愈合关系,结果示：缺损大小和右-左分流的速度对于室间隔缺损的自然愈合率有影响,差异有统计学意义(P均≤0.05),缺损越小、右-左分流的速度越小,自然愈合的可能性越大。左-右分流的速度对室缺自愈率无明显影响。9.室间隔缺损大小、左-右分流及右-左分流速度与室间隔缺损自然愈合时间关系,结果示：缺损大小对室间隔缺损自然愈合的早晚有影响,缺损越小自然愈合时间越早,差异有统计学意义(P<0.01)。而左-右分流和右-左分流的速度对室间隔缺损自然愈合的早晚没有影响。研究结论：1.年龄与室间隔缺损的自然愈合之间有很大的关系,生后24个月以内自然愈合的几率较高。2.室间隔缺损部位、穿隔血流速度等因素对婴幼儿室间隔缺损自然愈合均有影响。不同缺损部位自然愈合率存在显著差异(χ2=7.355,P=0.007<0.05)3.室间隔不同缺损部位在不同时间段自然愈率无明显在差异(χ2=5.742,P=0.057)。4.室间隔缺损大小和右-左分流的速度对于室间隔缺损的自然愈合率有影响,差异有统计学意义(P均≤0.05),缺损越小、右-左分流的速度越小,自然愈合的可能性越大。5.心室左-右分流和右-左分流的速度对室间隔缺损自然愈合的早晚没有影响。6.研究结果用于指导室间隔缺损患儿临床手术治疗和优生优育有重要意义。更多还原

【Abstract】 ObjectiveObservation of fetal simple Ventricular septal defect of natural conditions, and on the impact of simple Ventricular septal defect natural healing related factors. Congenital heart disease (CHD) is most common in children with congenital malformations, by environmental factors and the role of genetic factors, multiple genes inherited diseases, the incidence rate of about 0.6% 1.2%. According to statistics, China’s congenital heart disease incidence in the normal population is approximately 8‰, is the most common newborn congenital malformation, is also an important neonatal and infant mortality. Every year the birth of children with congenital heart disease is about 15 million, isolated Ventricular septal defect is congenital heart disease in the most common type, accounting for about 25% to 40% of the total. Defects may occur in any part of the interventricular septum, such as film, outflow, and muscle. In some cases can intrauterine or within 3 years, after the birth defect gradually become smaller or natural healing. At present, the research more Echocardiogram screening and diagnosis of fetal period each kind of congenital heart disease and how to improve the accuracy of the diagnosis. In Stiimpflem, and more research emphasized the fetal echocardiography heart defect and other cannot diagnose the importance of the chromosome aberration, sensitivity of 88.5%, specificity 100% prenatal diagnosis of congenital heart disease the ultimate goal is to improve the prognosis. Maternal fetal echocardiography found serious malformations of the heart, eugenics of labor become obstetric clinic treatment. By screening, parents in prenatal was told the diagnosis of congenital heart disease, severity and prognosis is, severe complex malformations fetus timely termination of pregnancy. Accurate antenatal examination structure helps select the best delivery time, for the early treatment of newborn infants, to establish the correct congenital heart disease treatment options have a good guideline. The clinic also determines the necessary prenatal and postnatal care, thereby enhancing serious survival of infants. Echocardiography as a way to the fetus and the mother are non-invasive method of checking, Winsberg1972, the first reported use of M-fetal heart of results. In the early 1980s, Kleinmanji and Allan had established fetal echocardiography method, launched a prenatal diagnosis of congenital heart disease. With the rapid development of perinatal medicine, fetal echocardiography of applications, has been able to more accurately evaluate fetal cardiac structure and hemodynamics, available on most of the fetus to prenatal diagnosis of congenital heart disease. Fetal ultrasound ECG can be non-traumatic probe into the heart of fetal stages and internal diameter of the great vessels and heart valves, hemodynamics and fetal cardiac rhythm, etc., is not only an early diagnosis of congenital heart disease is safe and reliable means, more to further improve the prognosis of congenital heart diseases, improve neonatal survival to create good conditions. A large number of clinical data prove, congenital heart disease of prenatal monitoring will greatly improve the complex congenital heart disease, especially in the catheterization dependent diabetes and cardiac, vascular severe Dysplasia of congenital heart disease are serious cyanosis and acidosis. In recent years abroad has carried out-of-the-art surgical intervention in utero fetal congenital heart disease, some make the treatment of congenital heart disease have a significant breakthrough. To do this, we use color Doppler ultrasound screening for gestational age in 20 instrument-28 weeks pregnant women. In the heart of four Chamber view, left ventricular outflow tract and aortic long axis slice and other heart more slices, observation of Ventricular septal whether echo interrupt and wear other blood flow. Find positive patients, to guide the children for the clinical examination, to merge the other malformations or other chromosomal abnormalities and other diseases; and conduct clinical Ventricular septal defect, and surgical treatment of time eugenics is important.Research methods:For more than 20 weeks of pregnancy, to pregnant women and giving the fetus necessity of congenital heart disease, as well as present echocardiography can screening and diagnosis of fetal heart disease categories, agreed after line of fetal cardiac ultrasound examination. Pregnant women supine, choice of fetal cardiac conditions, probe into maternal abdominal wall sliding, first determine fetal position, longitudinal scan fetal spine, probe rotate 90 degrees, crosscutting fetal cardiac chest being distinct four Chamber view, in this section of the observation by two-dimensional and a broad scale, proportion and atrioventricular cavity size, mitral and tricuspid valve (location, development, and open the case, there is no atrial septum, oval hole size, Ventricular septal continuity and whether there is a space-occupying lesions, and so on, change the beam direction for left ventricular long axis slice, but short axis slice, left ventricular outflow tract, right ventricular outflow tract and aorta and pulmonary long axes, and other slice, further study of fetal cardiac and vascular structures, forms; positive case before delivery (37-40 weeks) once, record the same project-related data. Postpartum month using echocardiography review neonates, for children and of children, every six months follow-up review, follow-up of 3 years. Each group of data entry SPSS12.0 statistical software, the software process, look for related factors and correlation coefficient. Fetal confirmed Ventricular septal defect before review after giving birth. After a month use color Doppler ultrasound reinspection neonatal cardiac instrument, for Ventricular septal defect is an unclosed children, every six months follow-up review once, continuous follow-up of 3 years. The two color Doppler ultrasonography is not found to confirm AV streaming Ventricular septal defect of healing. Using computer software SPSS 15.0 single factors and factors related to statistical analysis.Results:1, Simple Ventricular septal defect 126 cases, where labor front defect intrauterine natural healing in 2 cases, after giving birth to complete follow-up 86 cases.2,86 cases, surgical treatment of 17 cases, postnatal Ventricular septal defect natural healing 55 cases,10 cases of defect follow-up 3 years is still not healing,4 cases of early postnatal complications due to different.3,55 cases,12 months defect natural healing and 28 cases,49.1 percent,24 months defect natural healing 52 cases, only 91.2%, average (13.7±8.5). 4, The natural healing of peak in 24 months.5,Ventricular septal defect occurred in 52 cases muscle of 48 cases of natural healing, accounted for 92.3%, occur in Ventricular septal upper section 14 cases of nine cases of natural healing,64.3%, and different parts of the natural healing rate of defects by the Chi-square test confirmed that there are significant differences between (χ2=7.355, P=0.007<0.05))6,Affect Ventricular septal defect natural healing time related factors:VSD infant within 3 years of natural healing time varies, break it into 1-12 months,13-24 months and 25-36 months three stages, the defect parts of VSD, size and other blood flow velocity, and the relationship between defect healing time.7. the defect parts and Ventricular septal defect healing relationship: Ventricular septal defect, muscles before and after 0-12 months natural healing of sample size and more, for 26 cases (54.2%), and Ventricular septal defect is on postnatal 13-24 months natural healing of sample size and more,7 patients (77.8%), but in different parts of defect in different time periods of natural healing rate of no significant difference in ((χ2=5.742,P=0.057))8. the Ventricular septal defect size, left-right shunt and right-left shunt speed and Ventricular septal defect natural healing relationship, the result looks like this:defect size and right-left shunt speed for Ventricular septal defect of natural healing effects, there are differences are statistically (P is≤0.05), the smaller the defect, right-left shunt the small, the likelihood of a natural healing. Left-right Division of speed on the VSD self-healing rate no appreciable effect.9. the Ventricular septal defect size, left-right shunt and right-left shunt speed and Ventricular septal defect natural healing time constraint, the result looks like this: defect size on Ventricular septal defect natural healing effects, sooner or later have a defect with the smaller natural healing time sooner, differences are statistically (P< 0.01). While the left-right and right-left shunt speed on Ventricular septal defect natural healing and evening has no effect.Conclusions:1, Age and Ventricular septal defect of natural healing are very closely related, born within 24 months after the natural healing of the weak..2, Ventricular septal defect parts, other factors such as blood flow velocity on infant Ventricular septal defect natural healing. Different defect parts of natural healing rates there are significant differences between (χ2=7.355, P=0.007<0.05)3. Ventricular septal defect parts in different for different time periods natural healing rate no obvious difference in (χ2=5.742,P=0.057)。4. Ventricular septal defect size and right-left shunt speed for Ventricular septal defect of natural healing effects, there are differences are statistically (P is≤0.05), the smaller the defect, right-left shunt the small, the likelihood of a natural healing.5. the ventricular shunt and the left-right and right-left shunt speed on Ventricular septal defect natural healing and evening has no effect.6. study results to guide clinical Ventricular septal defect with eugenics is important更多还原