本文選題：先心病室間隔缺損合并肺高壓 + T-bet　； 參考：《河北醫(yī)科大學(xué)》2012年碩士論文

【摘要】：目的：先心病室間隔缺損(ventricular septal defect, VSD)簡稱室缺，是最常見的先心病之一，約占23～30%�；純撼錾笥捎诜窝h(huán)打開，使肺動脈壓力驟減，右室壓力也隨之減小，使左右室壓差顯著。當室間隔出現(xiàn)缺損時，則左室血液將有一部分經(jīng)缺損流入右心室，長期左向右分流，使肺小動脈中層增生，內(nèi)膜增厚，肺血管阻力進一步增加，形成肺動脈高壓，如果沒有及時治療，肺小動脈病變進行性加劇，形成不可逆性肺血管阻塞性病變，肺血管阻力甚至超過體循環(huán)的阻力，導(dǎo)致右向左分流，患兒出現(xiàn)紫紺，即艾森曼格綜合癥。 肺動脈高壓(pulmonary arterial hypertension, PAH)是先心病室間隔缺損(VSD)最常見的并發(fā)癥。另外，VSD患兒在圍手術(shù)期可出現(xiàn)PAH危象，是圍手術(shù)期死亡的重要原因之一。國內(nèi)對于低月齡、低體重的VSD合并PAH患兒的外科治療，與國際先進水平尚有相當大的差距，是當今我國小兒心外科的主要挑戰(zhàn)之一。 有研究報道先心病患兒存在免疫功能低下和免疫功能紊亂，即存在Thl→Th2漂移，并且肺充血型先心病較肺缺血型先心病患兒免疫功能紊亂更為明顯。Th1、Th2及其相互之間的平衡在免疫應(yīng)答中起著關(guān)鍵作用。在T細胞亞群分化過程中，轉(zhuǎn)錄因子具有重要的調(diào)節(jié)作用。轉(zhuǎn)錄因子T-bet和GATA-3分別特異性地表達于Th1和Th2，是決定Th0細胞向Thl細胞或Th2細胞分化的兩個關(guān)鍵且特異性轉(zhuǎn)錄因子。 實時熒光定量PCR是一種基于傳統(tǒng)PCR檢測方法上的新技術(shù)，它有效地解決了傳統(tǒng)定量只能終點檢測的局限，具有高特異性和可靠性，實驗結(jié)果穩(wěn)定，重復(fù)性好等優(yōu)點。 本實驗擬通過檢測小年齡、低體重室間隔缺損合并不同程度肺高壓患兒圍手術(shù)期外周血單核細胞(Peripheral blood mononuclear cells, PBMCs)中轉(zhuǎn)錄因子T-bet mRNA和GATA-3mRNA的表達水平，從調(diào)控轉(zhuǎn)錄水平探討Th1和Th2細胞在先天性室間隔缺損合并不同程度肺高壓圍術(shù)期免疫功能紊亂中的作用及意義。 方法：2011年3月至2011年12月在本院心臟外科住院接受先心病手術(shù)治療并符合以下條件的VSD合并不同程度PAH患者，入選標準：①所有病例均經(jīng)體檢、輔助檢查及彩色心臟超聲檢查確診為先天性心臟病室間隔缺損患者，年齡1歲以內(nèi)，體重＜10Kg；②嚴格按照納入標準選VSD合并輕度PAH (肺動脈壓/主動脈壓在0.3～0.45)、中度PAH (0.45～0.75)、重度PAH (＞0.75)以及未合并PAH者各10例，所有入選患兒均在體外循環(huán)開始前直接測壓，確定肺高壓程度；③所有患兒其他臟器無嚴重疾病史，無其它缺氧相關(guān)疾病史，無嚴重感染和自身免疫性疾病史；④排除原發(fā)性肺動脈高壓；⑤本實驗經(jīng)河北省兒童醫(yī)院倫理委員會批準，患兒家屬簽署知情同意書。 研究對象抽取外周靜脈血，采用SYBR GreenⅠ實時熒光定量RT-PCR技術(shù)檢測PBMCs中轉(zhuǎn)錄因子T-bet mRNA和GATA-3mRNA的表達水平。所有數(shù)據(jù)應(yīng)用SPSS13.0統(tǒng)計軟件分析，，多組間比較用單因素方差分析。P0.05有統(tǒng)計學(xué)意義。 結(jié)果： 1先心病室間隔缺損合并不同程度PAH患兒(共4組)之間的統(tǒng)計比較結(jié)果如下： 1.1T-bet基因的統(tǒng)計結(jié)果：無PAH組、輕度PAH組、中度PAH組、重度PAH組ΔCt值分別為5.74±2.15、6.93±1.45、7.51±1.96、7.43±1.31。先天性室間隔缺損合并中度PAH組T-bet基因的表達較未合并PAH組低(P=0.024＜0.05)；先天性室間隔缺損合并重度PAH組T-bet基因的表達較未合并PAH組低(P=0.033＜0.05)；其余各組之間無差別(P＞0.05)。 1.2GATA-3基因的統(tǒng)計結(jié)果：無PAH組、輕度PAH組、中度PAH組、重度PAH組ΔCt值分別為3.79±2.10、5.43±1.29、5.36±1.36、5.35±1.20。先天性室間隔缺損合并輕度PAH組GATA-3基因的表達較未合并PAH組低(P=0.025＜0.05)；先天性室間隔缺損合并中度PAH組GATA-3基因的表達較未合并PAH組低(P=0.018＜0.05)；先天性室間隔缺損合并重度PAH組GATA-3基因的表達較未合并PAH組低(P=0.020＜0.05)；其余各組之間無差別(P＞0.05)。 2先心病室間隔缺損在圍手術(shù)期(術(shù)前、術(shù)后1d、術(shù)后3d、術(shù)后7d)，各組之間的統(tǒng)計比較結(jié)果如下： 2.1T-bet基因的統(tǒng)計結(jié)果：先心病室間隔缺損在圍手術(shù)期術(shù)前、術(shù)后1d、術(shù)后3d、術(shù)后7dΔCt值分別為5.97±1.49、6.74±2.29、7.30±1.22、7.17±1.27。術(shù)前患者T-bet基因的表達較術(shù)后3d患者低(P=0.045＜0.05)；術(shù)前患者T-bet基因的表達較術(shù)后7d患者低(P=0.002＜0.05)；術(shù)后1d患者T-bet基因的表達較術(shù)后7d患者低(P=0.038＜0.05)；其余各組之間無差別(P＞0.05)。 2.2GATA-3基因的統(tǒng)計結(jié)果：各組之間均無統(tǒng)計學(xué)差別（P值均＞0.05）。 結(jié)論：本研究從轉(zhuǎn)錄水平上提示先天性室間隔缺損合并不同程度PAH患兒的在圍手術(shù)期存在免疫功能紊亂。先天性室間隔缺損合并中、重度PAH組T-bet基因的表達較未合并PAH組低，即先天性室間隔缺損合并中、重度PAH組患兒Th1細胞數(shù)量減少的可能性大，可能存在細胞免疫下降；先天性室間隔缺損合并輕、中、重度PAH組GATA-3基因的表達較未合并PAH組低，即先天性室間隔缺損合并輕、中、重度PAH組患兒存在Th2細胞數(shù)量減少的可能性大，可能存在體液免疫也降低；先心病室間隔缺損在圍手術(shù)期(術(shù)前、術(shù)后1d、術(shù)后3d、術(shù)后7d)，各組之間的統(tǒng)計比較結(jié)果提示患兒在術(shù)后第1d、3d、7d時T-bet基因的表達均降低，即術(shù)后均存在Th1細胞數(shù)量減少，細胞免疫下降，第3d最低，7d后開始恢復(fù)，但并未達到正常水平；術(shù)前及術(shù)后體液免疫未見明顯變化。
[Abstract]:Objective: ventricular septal defect (VSD) is one of the most common congenital heart disease, which accounts for about 23 to 30%. of children after the birth of the pulmonary circulation, the pulmonary artery pressure is reduced, the right ventricular pressure decreases, and the left and right ventricular pressure is significant. When the ventricular septal defect occurs, there will be a part of the left ventricle blood. Through the defect into the right ventricle, the long-term left to right shunt, the middle layer of pulmonary artery hyperplasia, the thickening of the intima, the pulmonary vascular resistance to further increase, the formation of pulmonary hypertension, if not timely treatment, the pulmonary arteriopathy is aggravated, the formation of irreversible pulmonary vascular obstruction venereal disease, pulmonary vascular resistance even more than body circulation resistance, leading to right Left to shunt, children with cyanosis, that is, Eisen Mange's syndrome.
Pulmonary arterial hypertension (PAH) is the most common complication of ventricular septal defect (VSD). In addition, the PAH crisis can occur in children in the perioperative period of VSD, which is one of the important causes of perioperative death. The surgical treatment of low month, low weight VSD with PAH in children and the international advanced level of Shang Youxiang The big gap is one of the main challenges of pediatric cardiac surgery in China.
Some studies have reported that children with congenital heart disease have low immune function and immune function disorder, that is, there is Thl to Th2 drift, and the immune function disorder of the pulmonary blood type congenital heart disease is more obvious than that of the pulmonary ischemic congenital heart disease in children with.Th1. Th2 and the balance between them play a key role in the immune response. In the process of the differentiation of T cell subsets, the transcription is transcribed. Factor T-bet and GATA-3 are specifically expressed in Th1 and Th2, respectively, which are two key and specific transcription factors that determine the differentiation of Th0 cells into Thl or Th2 cells.
Real time fluorescence quantitative PCR is a new technology based on traditional PCR detection method. It effectively solves the limitation of traditional quantitative detection only. It has the advantages of high specificity and reliability, stable experimental results and good repeatability.
This experiment is to detect the expression of T-bet mRNA and GATA-3mRNA in peripheral blood mononuclear cells (Peripheral blood mononuclear cells, PBMCs) in children with small age and low weight ventricular septal defect combined with different degrees of pulmonary hypertension, and to discuss the combination of Th1 and Th2 cells in congenital ventricular septal defect with the regulation of transcription. The role and significance of perioperative pulmonary function disorder in the same degree of pulmonary hypertension.
Methods: from March 2011 to December 2011, the patients receiving congenital heart disease in our hospital heart surgery were treated with VSD and the following conditions were combined with different degrees of PAH. The criteria were selected: (1) all cases were diagnosed as congenital heart disease ventricular septal defect by physical examination, auxiliary examination and color echocardiography, within 1 years of age and body weight. < 10Kg; (2) strictly according to the inclusion criteria, VSD combined with mild PAH (pulmonary arterial pressure / aortic pressure from 0.3 to 0.45), moderate PAH (0.45 ~ 0.75), severe PAH (> 0.75) and 10 cases without PAH, all the selected children were directly measured before cardiopulmonary bypass to determine the degree of pulmonary hypertension; third, there were no serious diseases in other organs of all children. History, no other history of hypoxia related diseases, no serious infection and the history of autoimmune diseases; 4. Elimination of primary pulmonary hypertension; 5. This experiment was approved by the ethics committee of Hebei children's Hospital, and the families of the children signed the informed consent.
The study subjects extracted peripheral venous blood and detected the expression level of T-bet mRNA and GATA-3mRNA in PBMCs by SYBR Green I real-time fluorescence quantitative RT-PCR. All data were analyzed with SPSS13.0 statistical software, and the single factor variance analysis of.P0.05 was statistically significant in multiple groups.
Result錛

本文編號：1899213