心脏瓣膜病2-.ppt

单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Valvular Heart Disease,心脏瓣膜病,心脏瓣膜病,是指心瓣膜及瓣下装置由于炎症、变性、粘连、缺血性坏死、创伤、老化或钙质沉着及先天性发育异常等原因，使单个或多个瓣膜发生急性或慢性的狭窄或关闭不全，导致前向血流障碍和/或返流的一组疾病。临床上最常受累的为二尖瓣，其次为主动脉瓣。,风湿性心脏病,简称风心病，仍是我国主要的心脏病，是风湿性炎症过程所致瓣叶损害。根据人群发病率调查已有下降趋势。,Mitral valve disease,二尖瓣疾病,Mitral stenosis (MS),二尖瓣狭窄,Etiology and Pathology（病因和病理）,Rheumatic heart disease(风湿性心脏病),Congenital malformation(先天性畸形),Senile mitral annulus and subvalvular calcification(老年人二尖瓣环及环下区钙化,),Pathophysiology(病理生理),The cross-sectional area of the mitral valve orifice(瓣环口面积）,Normal adults 4,-,6cm,Mild MS,2cm,Moderate MS,1.5cm,Severe MS,1.0cm,The effect on LA and cardiac output of MS,Mild MS,：,LA,压力轻度升高，心排血量正常,Severe MS,：,跨瓣压差增大,(20,mmHg),LA,压力升高（,25,mmHg,)；,休息时心排血量正常或减少,The effect on the pulmonary circulation and respiration of elevated left atrium pressure,LA,PVP、PCP,lung congestion/pulmonary edema pulmonary artery intima hyperplasia and thickening（肺动脉内膜增生肥厚）PAP（肺动脉压升高）Right heart failure（右心衰竭）,Remarks(备注),PAP：肺动脉压,PCP：肺毛细血管压,PVP肺静脉压,Clinical situation(临床表现),一、Symptom(中度狭窄始出现症状),Exertion,dyspnea,(,劳力性呼吸困难),Hemoptysis,(,咯血),支气管静脉压破裂出血,肺梗死,肺水肿,Hoarseness（,声嘶）,Cough(,咳嗽）,LA,增大压迫左主支气管，支气粘膜淤血水肿，易致感染,扩大的,LA、,肺,A,压迫喉返,N,Clinical situation,二、Physical Sign(体征),Mitral facies(二尖瓣面容),S,1,，可闻及OS(开瓣音),Cardiac apex DM(心尖区舒张期杂音），often accompanying diastolic thrill(舒张震颤）,RV，P,2,excessive(亢进)，Relative SM of TI(相对性三尖瓣关闭不全收缩期杂音),Laboratory examination(实验室检查),XRay,二尖瓣型心：左房右室大，主动脉结缩小，肺动脉扩张，肺淤血,ECG,P,0.12s,RV,1,电轴右偏，心房纤颤，粗f波,Echocardiogram(超声心动图)：是确诊、定量MS的可靠方法,M,型：二尖瓣前后叶同向运动,二维：狭窄瓣膜形态结构，瓣口面积，房室大小,连续多普勒：测定血流速度、跨瓣压差,Cardiac catheterization(,心导管术),测定肺毛细血管压和左室压，确定跨瓣压差，明确狭窄程度,Diagnosis and Differential diagnosis(诊断和鉴别),Diagnosis,心尖区DMLA扩大及实验室检查可诊断，超声有确诊价值,Differential diagnosis,二尖瓣口血流增加,Austin Flint杂音,左房粘液瘤：随体位改变的DM,Complication（并发症）,一、Atrial fibrillation(心房纤颤),见于5%以上的患者；房颤使心排量下降20%，常是体力活动明显受限的开始,二、Acute pulmonary edema(急性肺水肿),为重度MS最严重的并发症及致死原因,三、Embolism(栓塞),80%有房颤、大左房（D55mm)；2/3为脑栓塞，也可有周围及内脏栓塞,Complication（并发症）,四、Right heart failure(右心衰竭),五、Pulmonary infection(肺部感染),Prognosis(预后),无症状者可存活多年，一旦有症状至致残平均7.4年,死亡原因多为上述并发症,Therapy(治疗),General therapy(,一般治疗)：预防风湿热及感染性心内膜炎,Hemoptysis,(,咯血)：减低肺静脉压力,Atrial,fibrillation：,快速心室率时应用洋地黄,Right heart failure：,以利尿为主,Therapy(治疗),Acute pulmonary edema：,处理同急性左心衰；注意二尖瓣狭窄时用正性肌力药物不好，仅当房颤快速心室率时应用,Mechanic therapeutics(,机械治疗,),MS：,经皮球囊二尖前瓣成型术；外科手术,Mitral incompetence:MI,二尖瓣关闭不全,Etiology and Pathology（,病因病理）,During systole,competence(关闭)of mitral valve depend on the integrity of mitral structure and function(including leftlets of valve,mitral annulus(瓣环),tendinous cords(腱索),papillary muscle(乳头肌)and LV.Every abnormality may lead to MI.,一、Chronic MI,Rheumatic heart disease:The,leftlets,of,mitral,valve,fibrose,thicken,shorten and often accompany MS and aortic valve disease,Mitral,valve,prolapse,(,二尖瓣脱垂),CHD：Chronic,ischemia,(,缺血),or infarction(,梗死,),lead to fibrosis and functional disorder of papillary muscle,一、Chronic MI,Calcification of,mitral,ring and,subvalvular,(,二尖瓣环及环下区钙化),Infective,endocsrditis,Rupture of,chordae tendineae,(unknown cause),LV enlarged significantly(,左室显著扩大),Else,二、Acute MI,Rupture of,chordae tendineae,(,腱索,断裂),Endocarditis,leads to the,leftlets,of valve destruction(,心内膜炎致瓣叶毁损),Acute myocardial infarction(,急性心肌梗死),Trauma results in rupture of the,mitral,valve component(,创伤使二尖瓣器破裂),Rupture of prosthetic valve(,人工瓣膜开裂),Pathophysiology,MI,LVEDV,LV hypertrophy,LVEDP,LA,LV,failure,Pulmonary congestion,PAP,Right heart failure,Clinical situation(临床表现),一、Symptom,轻度MI可终身无症状，严重MI心排血量减少，感乏力、呼吸困难,二、Physical Sign,Heaving apex impulse(抬举性心尖搏动),Cardiac sound：S1（重度MI），S2分裂，闻及S3,Cardiac murmur：从S1后立即开始，与S2同时终止的SM，可伴收缩期震颤，向右腋、右肩胛下区传导；乳头肌功能不全、腱索断裂的杂音似海鸥鸣叫样,Laboratory examination,XRay,ECG,Echocardiogram,二维超声：可显示二尖瓣的形态结构，提供心室大小，明确病因,彩超连续多普勒：可用于二尖瓣心房侧探及收缩期射流，半定量返流量,Diagnosis and Differential diagnosis,心尖区SM心房、心室增大，诊断MI可成立，确诊有赖于超声心动图,应与以下情况相鉴别：,Tricuspid incompetence（,三尖瓣关闭不全）：胸左缘4、5肋间,SM，,可传至心尖区，杂音吸气时增强，伴颈静脉收缩期搏动,，,RV,VSD（,室间隔缺损）,Systolic ejection murmur in left border of sternum,生理性杂音,功能性杂音,主、肺动脉根部扩张,左或右室流出道梗阻,Atrial,fibrillation,Infective,endocarditis,Embolism,Heart failure,Complication,Prognosis,急性严重返流者，若不及时手术，极难存活,慢性MI无症状期长，一旦发生左心衰竭，预后不良,Therapy,Medical therapy(内科治疗),Prevent endocarditis and rheumatic fever,Patients who are asymptomatic and having normal cardiac function neednt therapy but regular follow-up(定期随访).,Complication are cured in patients with complication.,Surgical treatment,Prosthetic valve replacement,为主要手术方法，趋向早期手术,有症状者应在,LVEF0.5，,平均肺动脉压 20,mmHg,之前手术,产生左室功能不全、,LVEF 0.30.5、,年龄55岁、,LVEDD80mm，,已不置换瓣,Valvuloplasty of,mitral,valve(,二尖瓣整复术),优点：不需长期抗凝，,LV,功能恢复较好,Aortic Valve Disease,主动脉瓣疾病,Aortic stenosis(AS),主动脉瓣狭窄,Etiology and Pathology,Rheumatic heart disease：,风湿性炎症所致瓣膜交界处融合、瓣叶纤维化、钙化，引起瓣叶狭窄畸形，多伴,AI,及二尖瓣损害,Congenital bicuspid valve(,先天性二叶瓣),Senile,calcific,(degenerative)AS(,退行性老年钙化性主动脉瓣狭窄)：65岁老年人,AS,的常见原因，瓣叶主动脉面钙化结节限制瓣叶活动,Pathophysiology,The cross-sectional area of the aortic valve orifice(瓣环口面积）,Normal adult 3.0cm,The area,1.0cm,LVSP,transvalve pressure gradient manifest(,跨瓣压差明显,),ASAfter loadingLV hypertrophyLVEDP,LA amplification,PAP PCP,Lung congestion and edema,Myocardial ischemia,Myocardial contractility,Heart failure,Clinical situation,Symptom,AS Triple syndrom(AS三联症),Dyspnoea(,呼吸困难,):Lung congestion,Angina(心绞痛),Causing by,Synocope(晕厥),cardiac output,Clinical situation,Physical sign,Cardiac sound:S1 is normal,S2 is paradoxical splitting(,逆分裂),S4 may be heard,Cardiac murmur:：SM is heard on the second,intercostal,space(,肋间),of right border of sternum,and radiate to cervical part(,颈部,),left inferior border of sternum and cardiac apex accompanying thrill,Cardiac dilatation(,心脏扩大)，,SBP and pulse pressure decrease,Laboratory examination,X-Ray：,心影可正常或稍大，晚期见肺淤血,ECG：,可有左室,肥厚劳累征，及各种心律失常,Echocardiogram：,为确定、定量,AS,的重要方法,Cardiac catheterization：,可根据左室-主动脉压差计算瓣口面积,Diagnosis and Differential diagnosis,Diagnosis,典型的收缩期杂音，易于诊断；多瓣膜病变提示风心病,单纯AS：根据年龄，应考虑单叶瓣、二叶瓣膜及老年退行性变，确诊有赖于超声心动图,Differential diagnosis,AS应与左室流出道梗阻性疾病鉴别,Complication,Arrhythmia：10%,可发生房颤、窦性心律失常、房室传导阻滞，可至猝死、晕厥,Infective,endocarditis,Embolism,Heart failure：,发生左心衰后，病情迅速恶化,Gastrointestinal hemorrhage(,胃肠道出血)：15-20%胃肠道血管发育不良,Prognosis,一旦出现症状，平均寿命仅三年。,死亡原因为：左心衰、猝死,人工瓣膜置换术后，远期存活率优于内科治疗,Medicine therapy,Principal objective：确定狭窄发生度、观察病情进展，争取手术机会择期手术,Methods,预防感染性心内膜炎、风湿热,AS不能耐受房颤，一旦出现即时转复,处理心衰,PBAP:Percutaneous balloon aortic valvuloplasty,(经皮球囊主动脉瓣成形术),适用于高龄患者、不宜换瓣及妊娠等情况，作为姑息治疗,Aortic incompetence,主动脉瓣关闭不全,Etiology and pathology,一、Chronic AI,（一）：Aortic valve,disease,Rheumatic heart disease:,占2/3，由于瓣叶纤维化、增厚缩短，影响闭合，常合并,AS,及二尖瓣损害,Infective,endocarditis,:,为单纯,AI,的常见病因,Congenital malformation:,先天性二叶瓣、室间隔缺损伴一叶瓣脱垂、先天性主动脉瓣穿孔,Aortic valve,mucinous,degeneration(,主动脉瓣粘液样变性):可致主动脉瓣脱垂,Etiology and pathology,（二）：A,orta root dilatation：瓣环扩大，瓣叶关闭不全,Syphilitic,aortitis,(,梅毒性主动脉炎)：主动脉炎致主动脉根部扩张,30%呈,AI,Marfar,s syndrome：,为遗传性结缔组织病，升主动脉呈梭形扩张，常伴二尖瓣脱垂,Severe hypertension or,atherosclerosis,Idiopathic dilatation of ascending aorta(,特发性升,主动脉扩张),Etiology and pathology,二、Acute AI,Infective,endocarditis,Trauma,Dissection of aorta(,主动脉夹层分离):夹层血肿使主动脉瓣环扩大，或瓣叶、瓣环被夹层血肿撕裂，多见于马凡氏综合征、高血压或妊娠,Rupture of prosthetic valve(,人工瓣膜破裂),Pathophysiology,Chronic aortic regurgitationLVEDVSBP of LA,after many years,DBP of aortaangina LVEDP,Pulse pressure LV dilating and hypertrophy ,Peripheral vascular sign LAP、PVP,Left heart failure,Remarks(备注),SBP：收缩压DBP：舒张压,PVP：肺静脉压LAP：左房压,LVEDP：左室舒张末压,Peripheral vascular sign：周围血管征,Clinical situation,Physical Sign:SP,DP,DBP,1.Peripheral vascular sign,Water-hammer pulse(水冲脉),Pistol shot sound(枪击音),De musset signs(点头运动）,Duroziez signs(杜氏双重杂音),Capillary pulse(毛细血管搏动),Carotid artery pulse(颈动脉搏动),Clinical situation,Physical Sign,2.Apical impluse displaced to left and down(心尖搏动向左下移位),3.Cardiac sound：S1、S2减弱，可闻及S3,4.Cardiac murmur：舒张早期杂音，吹风性，呼气末期易闻及，于左胸第三肋间明显。重度返流者，心尖区可闻及舒张早期隆隆样杂音（Austin Flint杂音）,Laboratory examination,X-Ray：急性者心脏大小正常；有肺淤血、肺水肿者，心胸比值增大，LV、LA增大，升主动脉扩张及左心衰、肺淤血,ECG：LV肥厚劳损,Echocardiogram,Diagnosis and Differential diagnosis,Diagnosis,典型杂音周围血管征,Differential diagnosis,与Graham Stell 杂音的区别：见于严重肺动脉高压及肺动脉扩张的肺动脉瓣关闭不全,Austin Flint 杂音与MS杂音鉴别,Complication,Infective endocarditis,Ventricular arrhythmia(室性心律失常),Heart failure,Therapy,对于急性AI，外科治疗为根本措施,Medicine therapy mainly include：,预防感染性心内膜炎、风湿热,无症状的轻、中度,AI,者定期随访，限制体力活动,心衰时强心、利尿及血管扩张药物、对症治疗,Therapy,Surgical treatment：严重AI，需要换瓣治疗,Indications for surgery：,有症状的左室功能不全者,虽无症状，但已有左室功能不全，左室收缩末期容积增加，EF下降,Surgical contraindiction：LVEF0.15-0.20，LVEDD80mm，或 LVEDVI300ml/m,Multivalvular heart disease,多瓣膜病,Etiology,一种疾病同时损害几个瓣膜,一瓣损害相继引起近端瓣膜功能受累,不同疾病分别导致不同瓣膜损害,Pathophysiology,严重损害掩盖轻的损害,近端损害影响较显著，而掩盖轻的损害,总的血液动力学明显异常,Examples of common multivalvular heart disease,MS+AI：MS导致心排血量下降，使LV扩大延缓，周围血管缺如,MSAS：严重MS常掩盖AS的表现,ASMI：为危险的多瓣膜病，相对较少见。AS增加左室后负荷使MI返流加重，前向心搏量减少较二者单独存在时明显,Therapy,主要是择期手术,