儿童室间隔缺损自然闭合影响因素探讨

The study on the factors influencing natural closure of ventricular septal defect in children

目的探讨影响儿童室间隔缺损(VSD)自然闭合的因素。方法于1993-01—2006-01采用彩色二维多普勒超声心动图仪或实时三维心脏彩色多普勒超声仪对潍坊市人民医院儿科诊治的372例单纯VSD患儿进行多切面观察,充分显示VSD部位、游离缘,测量缺损大小、穿隔血流宽度、肺动脉收缩压(Pp)和双室内径等,并查X线胸片及体检。每3～6个月随访1次,最长随访时间8年。结果75例VSD自然闭合,确诊年龄(11.7±5.1)个月,闭合年龄(26.2±11.6)个月。6个月至3岁组闭合率最高(72.0%),后依次为<6个月组(13.3%),～6岁组(12.1%),～7岁组(2.7%);闭合组62例收缩期杂音消失,13例变为Ⅰ或Ⅱ级局限的收缩期杂音;闭合组均为小中型VSD,大型VSD无一例闭合,两组差异有显著性(P<0.01)。闭合组和未闭合组VSD直径分别为(8.7±3.6)mm、(13.7±4.8)mm,差异有统计学意义(P<0.01);单发VSD闭合率高于多发VSD(P<0.01);膜周部VSD闭合62例,肌部VSD闭合13例,干下型无闭合病例,差异有显著性意义(P<0.01)。肌部VSD闭合率高于膜周部(P<0.01);超声心动图(UCG)显示VSD游离缘不规整回声弱者闭合率显著高于游离缘规整回声强者(P<0.01);闭合组和未闭合组Pp分别为(27.2±11.7)mmHg(1mmHg=0.133kPa)、(39.2±12.6)mmHg,差异有统计学意义。Pp越高,自然闭合率越低,>50mmHg无闭合病例;闭合组左室舒张末径(LVEDD)、右室舒张末径(RVEDD)、心胸比率(C/T值)显著低于未闭合组(P均<0.01)。结论VSD患儿年龄,缺损大小、类型、数目、形态,Pp,心室大小是影响VSD自然闭合的因素。VSD游离缘回声弱且不规整形态可作为缺损有自然闭合趋势的重要标志。Pp监测对判定漏诊的多发VSD有一定价值。

Objective To investigate the related factors of natural closure of ventricular septal defect （VSD） in children. Methods Optimal diagnosis of VSD was obtained in 372 children with VSD by Two-Dimensional Echocardiography and Real-Time Three-Dimensional Echocardiography, showing detailed assessment of the position, free edge and size of VSD ,the width of blood stream, the pulmonary pressure （ Pp ） and the diameters of the left and right ventricles. All the patients received Physical and X-ray examination and were followed up once every 3 - 6 months for 8 years at most. Results Of the 372cases,75cases had closed natrually, whose diagnostic age ranged from 0. 6 months to 4.0 years old and closed age was from 3.5 months to 6. 5 years old. The closed rate was the highest in 6 months to 3 years old group, 〈 6 months group,3 -6 years group,and 6 - 7 years group successively. There were all smaller and middle VSD in closed group,and bigger in unclosed group,showing statistically significant change （ P 〈 0. 01 ）. The diameters of VSD were （ 8.7 ± 3.6 ） mm and （ 13.7 ± 2. 8 ） mm in closed group and unclosed group respectively （ P 〈 0. 01 ）. The closed rate of simple VSD was higher than that of multiple （ P 〈0. 01 ）. Totally 62 cases were permemhranous, 13 cases muscular,and no cases in sub-arterial infundibular in closed group,showing statistically significant change（ P 〈0. 01 ）. The closed rate of muscular VSD was higher than that of membranous （ P 〈 0. 01 ）. The closed rate of VSD with the irregular and less echo free edges was higher than that of the regular and more echo ones detected by Echocardiography （ P 〈0.01 ）. The Pp was（27.2 ± 4. 7） and （39.2 ± 12. 6） mmHg in closed group and unclosed group respectively,showing significant differences in them. No cases whose Pp was higher than 50mmHg could close naturally. There were significant differences of LVEDD,RVEDD,rate of C/T between closed group and unclosed group（ all P 〈0. 01 ）. Conclusion The patient＇s age,the size,type, number and shape of VSD,the Pp,and the diameters of left and fight ventricles were all factors affecting natural closure of VSD. The irregular and less echo free edge is a sign of VSD which can close naturally. The detection of Pp is useful for missed VSD.