兒科學(xué)教學(xué)課件：心血管

Problembasedlearning病例一患兒女性，

9月。發(fā)熱伴咳喘2天，發(fā)現(xiàn)心臟雜音1天。患兒自幼喂養(yǎng)困難，多汗，體重增長緩慢。無紫紺。心率130次/分，呼吸50次/分。心前區(qū)飽滿，可捫及震顫。左胸骨旁第3-4肋間聞及收縮期雜音IV級(jí)。P2增強(qiáng)，無明顯分裂。心尖區(qū)聞及舒張期雜音II級(jí)。如何臨床思考該患兒的雜音？進(jìn)一步臨床診斷和鑒別診斷？

病例一HeartMurmursPresentedbyDr.LiuFangSessionITheHeartSoundFirstheartsoundisproducedbyclosureoftheMVandTVThesecondsoundisproducedbyclosureoftheaorticvalveimmediatelyfollowedbyclosureofthepulmonicvalveTheHeartSoundSplittingofS2

NormalsplitingofS2WideInspiratorysplitting

Pulmonarystenosis---duetodelayedP2MitralregurgitationVSDDuetoearlyA2SplittingofS2

WideandFixedSplitASDRBBBTAPVDRightventricularfailure

RevisedSplittingLBBBAorticstenosisLeftVentricularFailurePDATheHeartSoundSingleS2

—DuetoinducedintensityofcomponentsofS2

pulmonaryatresiasevereTOF,TricuspidatresiaTruncusarteriosusAorticstenosis

—P2SynchronouswithA2

SingleVentriculeTheHeartSoundTheHeartSoundConditionscausingprominentS2Physiology(infantsandchildren)Lefttorightflow(largeQP/QS)PulmonaryhypertensionHyperdynamicventricularwithhighoutputConditionscausingWeakS2

PSTOFTheHeartSoundDifferentialDiagnosis-murmursFunctional/innocentmurmurs(normal)Physiologicmurmurs(duetoanabnormalityofflownotofprimarycardiacorigin)Pathologymurmurs(duetoanabnormalityofprimarycardiacorigin)Describingmurmurs:LocationTimingConductionPitchAmplitude(gradingIV)NatureofthemurmurRelationtoresperationandpostureDifferentialDiagnosis-murmursFunctional/innocentmurmurs(normal)

StillmurmurAged2toearlyadolescenceMayrelatedtoturbulentflowacrosstheleftventricularoutflowtractBestheardatleftlowersternalborderVenousHumNeverassociatedwithathrillDifferentialDiagnosisPhysiologicmurmurs(duetoanabnormalityofflownotofprimarycardiacorigin)

HighcardiacoutputstatesArteriovenousfistulaPeriferalpulmonicstenosisDifferentialDiagnosisPathologymurmurs(duetoanabnormalityofprimarycardiacorigin)

——systolicmurmur

VentricularseptaldefectAtrialseptaldefectPatentductusarteriosusAorticstenosisPulmonarystenosisMitralregurgitationTricuspidregurgitation

………PS,ASVSD,MR,TRSmallVSDorVSDwithPH,TRMVPDifferentialDiagnosisEarlyDiastolicmurmurMid-Diastolicmurmur(overload)Late-Diastolicmurmur(anatomic)Pathologymurmurs

——Diastolicmurmur

AorticregurgitationPulmonaryregurgitationMitralstenosisTricuspidstenosis

DifferentialDiagnosisPathologymurmurs

——Continuousmurmur

PatentductusarteriosusA-PwindowAVfistulaoraneurysmPAwithMPACA

ASDVSDPDA幾種常見先心病鑒別表VSDASDPDAPS分類左向右分流梗阻型（無分流）癥狀肺充血：呼吸道感染，心功能不全體循環(huán)血流降低：生長發(fā)育落后晚期：青紫通常無癥狀，重癥可有青紫及右心功能不全心臟體征雜音部位3、4LSB2、3LSB1、2LSB2、3LSB時(shí)期SMSMCMSM響度II~IV級(jí)II~III級(jí)II~IV級(jí)II~IV級(jí)傳導(dǎo)

廣泛局限頸部傳導(dǎo)廣泛，頸部震顫有無有有P2增強(qiáng)或亢進(jìn)增強(qiáng)或亢進(jìn)，固定分裂增強(qiáng)或亢進(jìn)減低，分裂X線表現(xiàn)肺血增多增多增多正?；驕p少肺動(dòng)脈段突出突出突出突出（狹窄后擴(kuò)張房室大小LV、LA、RV大RA、RV大LA、LV→RV大RV大心電圖LV、LA、RV大RBBB,RV大LA、LV→RV大RV肥厚21肌部VSD堵閉器膜周部VSD堵閉器（非對(duì)稱）膜周部VSD堵閉器（等邊）2224堵閉后2周，左室面堵閉后2周，右室面25右上肺動(dòng)脈造影顯示房缺球囊測量房缺大小ASD堵閉過程26堵閉器放置后經(jīng)胸超聲心動(dòng)圖監(jiān)測4歲男孩，PDA呈長管型，直徑1mm，采用彈簧圈成功堵閉PulmonaryStenosisAorticStenosisCoarctationoftheAorta,CoAStentimplantationforbranchpulmonarystenosis病例二患兒男性，1歲2月。生后6個(gè)月出現(xiàn)紫紺，并逐漸加重。平時(shí)無反復(fù)肺炎史，有蹲踞現(xiàn)象。3個(gè)月前突然有一次暈厥。生長發(fā)育落后，心率100次/分，呼吸30次/分，SPaO2:82%。左胸骨旁2-3肋間聞及收縮期雜音3-4級(jí)，噴射性。P2明顯減弱。

如何進(jìn)行診斷和鑒別診斷？為何蹲踞？暈厥原因？病例二RVLV肺動(dòng)脈狹窄：漏斗部、瓣膜及肺動(dòng)脈室間隔缺損（VSD）主動(dòng)脈騎跨（AO）右心室肥厚法洛四聯(lián)癥（TOF)病理基礎(chǔ)：動(dòng)脈圓錐隔分割不均杵狀指蹲踞姿勢：

體循環(huán)阻力增加腔靜脈回流減少保證重要器官血供

CyanosisPresentedbyDr.liufangSessionIICyanosis---HintsCentralcyanosis:impliesdecreasedarterialoxygensaturationPeripheralcyanosis:causedbyadecreasedrateofperipheralbloodflowDifferentialcyanosisDifferentialdiagnosisCardiovasculardisease -Congenitalheartdisease -Eisenmengersyndrome -Pulmonaryarteriovenousfistulae -Primarypulmonaryhypertension-Congestiveheartfailure/lowoutputstateDifferentialdiagnosisRespiratorydiseases -Nasalobstruction -Foreignbodyaspiration -Trachealcompression -Bronchiolitis -ReactiveairwaydiseaseDifferentialdiagnosis -RDS -Meconiumaspiration -Pneumonia -Pluraleffusion -Diaphragmatichernia -LunghypoplasiaDifferentialdiagnosisMetabolicdisease -HypoglycemiaNeurologicdiseases -Seizures -CerebralEdema -CerebralHemorrhageDifferentialdiagnosisMiscellaneous -Crying -Sepsis -Breathholding -Drug:respiratorydepressants胎兒循環(huán)產(chǎn)后循環(huán)危重的先天性心臟病

在胎兒期癥狀不明顯

生后即出現(xiàn)臨床癥狀肺血流嚴(yán)重的肺動(dòng)脈瓣狹窄室間隔完整的肺動(dòng)脈閉鎖法洛四聯(lián)征伴肺動(dòng)脈閉鎖并行循環(huán)：完全性大動(dòng)脈轉(zhuǎn)位左室流出道嚴(yán)重的主動(dòng)脈瓣狹窄,主動(dòng)脈閉鎖主動(dòng)脈縮窄

主動(dòng)脈弓離斷

左心室發(fā)育不良

綜合征肺靜脈回流異常完全性肺靜脈異位引流DifferentialdiagnosisDiscussionCardiovascular -NeonateswithcyanosisbyCHD1.PoormixingofthesystemicandpulmonarycirculationsPDATranspositionoftheGreatArteries(TGA)完全性大動(dòng)脈換位

（D-TGA）BalloonAtrialSeptostomy52BalloonAt