摘要目的：探讨静脉滴注硝酸甘油(nitroglycerin, NTG)对室间隔缺损合并充血性心力衰竭婴幼儿血流动力学影响。方法：15例室间隔缺损合并充血性心力衰竭婴幼儿，在连续监测心率和血压的情况下，静脉滴注NTG 0.4～0.8 μg^．kg^－1．min^－1，利用超声心动图在用药前、用药后1 h、6 h分别测定左心室射血分数（ejection fraction, EF）、短轴缩短率（fractional shortening, FS）、肺动脉平均压（pulmonary artery mean pressure, PAMP）、肺毛细血管楔压（pulmonary capillary wedge pressure, PCWP）和左心室壁应力（left ventricular wall stress, LVWS）等。结果：PCWP用药前(2.8±0.4) kPa，用药后1 h降至(1.7±0.4) kPa，6 h降至(1.6±0.4) kPa(P＜0.05)； LVWS Ⅰ用药前(4.32±0.56) N/cm²，用药后1h降至(3.65±0.59) N/cm²，6h降至(3.87±0.60) N/cm²(P＜0.05)；LVWS Ⅱ用药前(1.56±0.57) N/cm²，用药后1 h降至(1.33±0.55) N/cm²，6 h降至(1.30±0.57) N/cm²(P＜0.05)；LVWS Ⅲ用药前(2.64±0.54) N/cm²，用药后1h降至(2.26±0.57) N/cm²，6h降至(2.19±0.63) N/cm²(P＜0.05)，中期收缩应力用药前(1.48±0.43) N/cm²，用药后1h降至(1.33±0.28) N/cm²，6h为(1.37±0.38) N/cm²(P＜0.01)；静脉应用上述剂量NTG对心率、血压、EF、FS、PAMP及左向右分流量无明显影响。结论：小剂量静脉滴注NTG可降低PCWP和LVWS，而不影响其它血流动力学指标，具有改善小儿心力衰竭血流动力学的作用。

中国图书资料分类法分类号R541.1

Hemodynamic effects of intravenous nitroglycerin in infants and small children

with ventricular septal defect and congestive heart failure

ZENG He-Ping^＃, QIU Ye, WANG Dong-Ling, HAN Mei, LI Wan-Zhen, CHEN Yong-Hong, et al

(#Department of Pediatrics, the First Hospital, Beijing Medical University, Beijing100034)

MeSHHemodynamics/drug effNitroglycerin/pharmacolHeart septal defects, ventricular/physiopatholHeart failure, congestive/physiopathol

ABSTRACTObjective：To investigate the hemodynamic effect of intravenous nitroglycerin in infants and small children with ventricular septal defect (VSD) and congestive heart failure.Methods： Nitroglycerin at doses ranging from 0.4 to 0.8 μg．kg^－1．min^－1 was administered intravenously to 15 infants and small children with VSD and congestive heart failure under continuously monitoring heart rate(HR) and blood pressure(BP), left ventricular ejection fraction(EF), fractional shortening(FS), pulmonary artery mean pressure(PAMP), pulmonary capillary wedge pressure(PCWP) and left ventricular wall stress(LVWS) were measured by echocardiography before and at 1 and 6 hours after administration of nitroglycerin.Results： PCWP was reduced from (2.8±0.4) kPa before administration of nitroglycerin to (1.7±0.4) kPa at 1 h and (1.6±0.4) kPa at 6 h after administration of nitroglycerin(P＜0.05)； LVWS Ⅰ from (4.32±0.56) N/cm² to (3.65±0.59) N/cm² at 1 h and (3.87±0.60) N/cm² at 6h (P＜0.05)；LVWS Ⅱ from (1.56±0.57) N/cm² to (1.33±0.55) N/cm² at 1h and (1.30±0.57) N/cm²at 6h (P＜0.05)；LVWS Ⅲ from (2．64±0．54) N/cm² to (2．26±0．57) N/cm² at 1h and (2．19±0．63) N/cm² at 6h (P＜0.05)，mid-systolic stress from (1．48±0．43) N^．cm^－2 to (1．33±0．28) N^．cm^－2 at 1h and （1．37±0．38） N^．cm^－2 at 6h (P＜0.01) respectively. There were no significant effects of intravenous nitroglycerin at above dosages on BP, EF, FS, PAMP and left-to-right shunt etc..Conclusion： Small dosage of intravenous nitroglycerin to infants and small children with VSD and congestive heart failure could decrease PCWP and LVWS and had no effects on other hemodynamic indexes, which can improve hemodynamics in children with congestive heart failure.

(J Beijing Med Univ, 1999,31:555-557)

血管扩张剂是充血性心力衰竭治疗中的一个重要组成部分^［1］，但对小儿尤其是婴幼儿充血性心力衰竭治疗经验有限。本文对15例先天性心脏病室间隔缺损合并心力衰竭的婴幼儿应用静脉小剂量硝酸甘油(nitroglycerin, NTG)进行研究，以探讨静脉滴注NTG对婴幼儿血流动力学的影响。

1对象与方法

1.1对象

15例患儿年龄4～36月（平均12±6月），其中男9例，女6例，均为先天性心脏病室间隔缺损，无主动脉和二、三尖瓣病变，临床表现呼吸困难、三凹征、两肺细湿音，心率快、心音低钝、肝脏增大等，排除肺炎所致心力衰竭者。基础治疗包括地高辛、利尿剂等。

1.2用药方法

利用输液泵静脉滴注NTG 0.4～0.8 μg^．kg^－1．min^－1，维持时间6 h，分别在用药前及用药后1h、6h观测血流动力学变化情况。

1.3检测指标

应用菲利浦MD800彩色多普勒超声心动仪进行检测。测量指标：(1) 左心室舒张期内径和收缩末期内径；(2) 室间隔和左心室后壁舒张期和收缩期厚度；(3)右心室射血前期时间、射血时间和加速时间；(4) Q-C间期（心电图QRS波起点至M型超声心动图二尖瓣关闭点时间），A₂-E间期（心音图第二心音起始点至超声心动图二尖瓣开放最高点时间）；(5) 左心室射血分数（ejection fraction, EF）、短轴缩短率（fractional shortening, FS）、左室舒张末期容积指数（end diastolic volume index, EDVI）、每搏指数（stroke volume index, SVI）；(6)肺动脉血流量和主动脉血流量比值^［2］。上述测量指标选择3～5个心动周期取平均值。依据测量指标，计算肺毛细血管楔压(pulmonary capillary wedge pressure, PCWP)、肺动脉平均压(pulmonary artery mean pressure, PAMP)、左心室壁应力(left ventricular wall stress, LVWS)^［3］。

1.4统计学处理

结果以均值±标准差（±s）表示，采用双因素方差分析和Krusal-Wallis秩和检验及配对t检验对测量数据进行分析。P＜0.05为差异有显著性。

2结果

2.1NTG对血流动力学的影响

静脉NTG能降低室间隔缺损合并心力衰竭婴幼儿PCWP和LVWS，但对心率、血压、EF和FS、EDVI、PAMP没有明显影响（表1）。

表1硝酸甘油对室间隔缺损合并心力衰竭婴幼儿血流动力学影响（n=15）

Table 1Hemodynamic effect of nitroglycerin to infants and small children with VSD and CHF (n=15)

Indexes Before 1 h 6 h F P HR/min^－1 134±14 134±12 140±17 0.815 ＞0.05 SP/kPa 11.9±1.5 11.2±1.9 10.1±2.4 2.479 ＞0.05 DP/kPa 7.5±1.2 6.6±1.1 7.1±0.8 2.761 ＞0.05 EF 0.70±0.08 0.72±0.12 0.74±0.12 0.614 ＞0.05 FS 0.37±0.06 0.39±0.09 0.41±0.10 1.110 ＞0.05 EDVI/ml^．m^－2 52±33 54±36 56±39 1.408 ＞0.05 SVI/ml^．m^－2 68±15 72±15 66±17 0.159 ＞0.05 PAMP/kPa 5.3±0.5 5.5±0.6 5.0±0.9 2.194 ＞0.05 PCWP/kPa 2.8