心瓣膜病课件教案.pdf

心脏瓣联病(Valvular Heart Diseases,VHDJ二尖瓣狭窄(Mitral Stenosis,MS)MS:Etiology&Pathophysiology Rheumatic heart disease-Leaflet thickening,commissural fusion,chordal fusion Rarely congenital,or severe MV calcification(elderly)Normal mitral valve area(MVA):46 cm2-Mild mitral stenosis:MVA 1.5*2.5 cm2-Moderate mitral stenosis:MVA 1.0*1.5 cm2-Severe mitral stenosis:MVA 10 years since last episode and at least until age 40 y;sometimes lifelong prophylaxis Prophylaxis for infective endocarditis Diuretics or long-acting nitrates:ameliorate dyspnea p-blockers/digitalis/CCB:rate control,especially in AF Anticoagulation:In AF,LA thrombus or prior embolism上海瑞金医院施仲伟Mitral Stenosis:Intervention&Surgery Percutaneous MV balloon valvuloplasty(PMBV)Surgery for mitral stenosis-Mitral commissurotomy-Mitral valve replacementa.Mechanical valvesb.Bioprosthetic valves上海瑞金医院施仲伟二尖辩关闭不全(Mitral Regurgitation,MR)Mitral Regurgitation:Etiology Valvular-leaflets-Myxomatous(MV prolapse)-Rheumatic heart disease-Endocarditis-Congenital-clefts Papillary muscles-CAD(Ischemia,rupture)-HCM-Infiltrative disorders Annulus-Calcification,IE(abcess)Chordae tendineae-Fused/inflammatory-Torn/trauma-Degenerative-Infective endocarditis LV dilatation(functional reg.)上海瑞金医院施仲伟Mitral Regurgitation:Symptoms Symptoms-No symptoms at early stage(for several years)-Fatigue,dyspnea,orthopnoea Signs-Murmer-fixed MR:holosystolic blowing murmur-Murmer-dynamic MR(MVP):mid systolic,click-S1 soft or normal-A prominent S3上海瑞金医院施仲伟Mitral Regurgitation:ECG&CXR Electrocardiogram Chest X-ray Exam-LA enlargement-LV enlargement-Atrial fibrillation-LA enlargement-LVH-Pulmonary congestion-RVH-Mitral calcification-Combined hypertrophy-RV&RA enlargement上海瑞金医院施仲伟Mitral Regurgitation:Echo To diagnose MR and to quantify severity of MR To identify etiology-Flail leaflets(chord/papillary muscle rupture)-Rheumatic heart disease-Mitral valve prolapse(MVP)-Vegetations(infective endocarditis)-LV dilation To assess LV function and dimensions上海瑞金医院施仲伟Mitral Regurgitation:Medical Treatment Prophylaxis for recurrent rheumatic fever Prophylaxis for infective endocarditis Diuretics:for patients with CHF and dyspnea Vasodilators(controversial)-To reduce afterload&decrease regurgitation上海瑞金医院施仲伟Mitral Regurgitation:Surgical Treatment Mitral Valve Repair-Operation of choice if valve repairable Mitral Valve Replacement-Chordal preservation-Bioprosthesis vs mechanical valves Percutaneous Mitral Valve Repair(MitraClip)上海瑞金医院施仲伟主动脉瓣狭窄(Aortic Stenosis,AS)Aortic Stenosis:Pathophysiology Progressive LVOT obstruction leading to concentric LVH to normalize wall stress and to sustain cardiac output without LV dilation When the hypertrophic process is inadequate and relative wall thickness does not increase in proportion to pressure,wall stress increases,followed by ventricular dilatation and progressive decrease in systolic function上海瑞金医院施仲伟Aortic Stenosis:Symptoms A long asymptomatic“latent period Development of symptoms identifies a critical point in the natural history of AS:-Exertional angina:life expectancy is 5 years-Syncope:life expectancy is 3 years-Heart failure:life expectancy is 2 years-sudden death(15%20%?)上海瑞金医院施仲伟Aortic Stenosis:Physical Exam A Diamond shaped systolic ejection murmur:harsh,loud,radiates to the neck,with a concomitant systolic thrill Attenuated/absent aortic component of S2 Sustained apical systolic impulse上海瑞金医院施仲伟Aortic Stenosis:ECG and X-Ray ECG:LVH with ST-T changes(strain pattern)Chest X-Ray-Calcification of the aortic valve-Post-stenotic dilation of the ascending aorta-LV enlargement(late stage)上海瑞金医院施仲伟主动脉瓣狭窄：超声心动图 主动脉瓣解剖：增厚、钙化、瓣叶数目、瓣口面积 多普勒检查在升主动脉内探及收缩期高速湍流-连续波多普勒可定量血流速度,计算瓣口面积，计算跨瓣压力阶差 合并其他瓣膜病：二尖瓣病变、主动脉瓣关闭不全等 左室向心性肥厚及其程度 左室功能上海瑞金医院施仲伟Aortic Stenosis:Treatment Medical Therapy-Asymptomatic AS:close follow-up-Endocarditis prophylaxis-Sympatomatic treatment Percutaneous aortic balloon valvuloplasty Transcatheter aortic valve replacement(TAVR)Aortic valve replacement上海瑞金医院施仲伟主动麻辩关闭不全(Aortic Regurgitation)Aortic Regurgitation:EtiologyValvular Disease-Rheumatic disease-Calcific degeneration-Infective endocarditis-Bicuspid aortic valve-Traumatic injuries-Myxomatousdegeneration Aortic Root Disease-Systemic hypertension-Aortic dissection-syphilitic aortitis-Ankylosing spondylitis-Marfan syndrome-Age-related aortic dilation上海瑞金医院施仲伟主动脉瓣关闭不全：症状常数十年无症状,甚至可耐受运动 一般症状：胸痛，心悸，头晕，动脉搏动感 心绞痛（较主动脉瓣狭窄时少见）心力衰竭症状（晚期）：疲乏，呼吸困难上海瑞金医院施仲伟Aortic Regurgitation:Auscultation Early diastolic murmur immediately after A2-Upper RSB with root dilation-Mid to lower LSB with leaflet dysfunction Systolic murmur at base(similar to AS)Austin Flint murmur:a mid to late diastolic apical rumble上海瑞金医院施仲伟主动脉瓣关闭不全：其他检查心电图：左室肥大伴ST-T改变（”劳损）胸片-左室增大，升主动脉扩张（主动脉型心）-主动脉瓣钙化-左室衰竭征象（肺血管再分布，间质水肿）核素：左室功能（休息/运动时）；心肌灌流导管：返流程度；左室功能；冠脉解剖磁共振显像：诊断主动脉疾病（如夹层）准确性高上海瑞金医院施仲伟主动脉瓣关闭不全：超声心动图 主动脉瓣：增厚/钙化/脱垂/赘生物/瓣叶数目 主动脉根部：内径/有无夹层 舒张期返流：半定量返流程度（多普勒）合并其他瓣膜病：二尖瓣病变/主动脉瓣狭窄 左房左室大小室壁厚度及运动 左室功能上海瑞金医院施仲伟主动脉瓣关闭不全：内科治疗预防感染性心内膜炎预防风湿活动复发治疗伴发疾病（高血压/冠心病）避免/治疗心力衰竭诱发因素（心律失常/感染）无症状轻、中度反流者：限制体力活动+定期随访降低前、后负荷（血管扩张剂）利尿剂，洋地黄，硝酸盐（心绞痛时）上海瑞金医院施仲伟主动脉瓣关闭不全：外科治疗指征*-出现心力衰竭症状-左室收缩末期内径55mm（超声心动图）-左室射血分数50%方法：瓣膜置换术，瓣膜修复术*无症状且左心室功能正常的严重反流患者可不手术，但需密切随访上海瑞金医院施仲伟