0324心脏瓣膜病.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,*,心脏瓣膜病,(,Valvular heart disease),定义 (definition),心脏瓣膜病是由于炎症、粘液样变性、先天性畸形、缺血性坏死、创伤等原因引起的单个或多个瓣膜结构（包括瓣叶、瓣环、腱索或乳头肌）的功能或结构异常，导致瓣口狭窄和（或）关闭不全。二尖瓣最常受累，其次为主动脉瓣。,The valvular heart disease is the s,tructural and/or functional abnormality of cardiac valves resulting in,valvular stenosis and insufficiency because of infective,myxoma,congenital,ischemic necrosis and trauma.,常见瓣膜病变种类：,风湿性心脏瓣膜炎及瓣膜病,老年性退行性心瓣膜病,缺血性心脏病引起的急性瓣膜损害,先天性：,二叶式主动脉瓣,二尖瓣、主动脉瓣脱垂,二、三尖瓣裂缺等,已有瓣膜病基础上发生感染性心内膜炎的再损伤,3心脏杂音复习：,主要瓣膜杂音及其相关问题,出现时期 开关瓣 杂音性质 心音强弱 震颤 累及腔室,二狭 舒张期 开 隆隆样 S1增强 有 左房及后,二闭 收缩期 关 吹风样 S1减弱 无 左室及后,主狭 收缩期 开 喷射样 S2增强 无 左室及后,主闭 舒张期 关 叹气样 S2减弱 有 左室及后,上图表要点：,首先明确各瓣膜在收缩及舒张期 时是“开”还是“关”瓣；,明确各瓣膜的听诊位置；,“关闭不全”只有在关瓣时才表现，“狭窄”在开瓣时体现；,关闭不全致心音减弱，狭窄致心音增强。,Mitral valve disease,二尖瓣疾病,Mitral stenosis (MS),二尖瓣狭窄,病因(,Etiology,),二尖瓣狭窄的最常见病因为风湿热。其他病因有先天性畸形，老年人二尖瓣环钙化,系统性红斑狼疮和细菌性心内膜炎。,Almost always the result of rheumatic fever.,A latency period of 10-20 years,or more,after an episode of rheumatic fever;therefore,the onset of MS symptoms does not occur until then.,Less common causes include,mitral annulus,calcification co,ngenital MS,SLE,atrial myxoma,and bacterial endocarditis.,.,Pure MS develops in approximately 40%of all pts with RHD.,流行病学,Epidemiology,Frequency,-In the world:The prevalence of MS has decreased because of the decline in the occurrence of rheumatic fever in the world and developed countries.,发生率：,由于风湿热发病率的下降，在全世界二尖瓣狭窄的发生率亦明显下降。,Sex,-2/3 of all patients with MS are female.,性别：2/3发生于女性。,Age,-the onset of symptoms usually is between the third and fourth decades.,年龄：一般在3040岁发病。,病理生理,(Pathophysiology),二尖瓣狭窄程度的分类,The cross-sectional area of the mitral valve orifice(瓣环口面积）,Normal adults 4,-,6cm,Mild MS,1.5-,2cm,Moderate MS,1-,1.5cm,Severe MS,1.0cm,1左房代偿期：,为早期，轻度狭窄,跨瓣压差 20mmHg，左房平均压 20mmHg，左房平均压 25mmHg,明显左房压升高、肺淤血、肺动脉高压,有明显临床表现：,临床表现发生机制：,肺淤血、肺水肿类似急慢性左心衰竭左房衰竭,肺动脉高压、右室肥厚右心衰竭,升高的左房压后向性传递,二狭肺动脉高压 肺小动脉反应性收缩,产生的主要原因 肺血管床器质性闭塞性改变,反复肺部感染及过劳,分型,1隔膜型：,2漏斗型：,1隔膜型：,只累及瓣膜，并无明显孪缩,瓣膜弹性好，少有关闭不全,左心室不扩大,S1亢进，伴开瓣音,首选二尖瓣球囊成型术 （球囊扩张术）,2漏斗型：,累及瓣膜、腱索、乳头肌等,瓣膜弹性差，一般均伴关闭不全,S1减弱,二尖瓣置换术,临床表现,(,Clinical situation),一、症状 (Mitral stenosis-symptoms),（一）呼吸困难,(,dyspnea,),劳力性呼吸困难,exertive,dyspnea,Often triggered by exertion,fever,anemia,onset of Afib,or pregnancy.,端坐呼吸,Orthopnea,阵发性夜间呼吸困难,Paroxysmal nocturnal dyspnea,.,急性肺水肿,Acute pulmonary edema.,临床表现,（,二）咯血 Hemoptysis,1、突然咯大量鲜血 Expectoration of blood2、咳嗽时的血性痰或带血丝痰 Blood-tinged sputum,3、急性肺水肿时咳大量粉红色泡沫状痰 Pink,frothy sputum,（,三）咳嗽Cough,与支气管粘膜水肿或与左心房增 大压迫左主支气管有关。,（四）声 嘶 Hoarseness,二、,Physical Sign(体征),Mitral facies(二尖瓣面容)S1，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，P2 excessive(亢进)，Relative SM of TI(相对性三尖瓣关闭不全收缩期杂音),（二）肺动脉高压和右心室扩大的心脏体征Two:,the signs of,pulmonary pressures and RV dilation,由于 肺动脉扩张，在胸骨左上缘可闻及递减型高调叹气样舒张早期杂音（Granham Steell杂音）,an increased pulmonic S2 sound,Because of pulmonary dilation,it is heared of Graham Steells murmur.(high-pitched,decrescendo,diastolic murmur of pulmonary insufficiency),Jugular venous distention,Signs of right heart failure in severe MS include ascites,hepatomegaly,and peripheral edema.,实验室和其他检查,Imaging Studies,一、X线检查,Chest radiography,左心房增大，右心缘有双心房影，右前斜位可见增大的左房压迫食管下段后移。其他征象包括右心室增大，肺动脉干和次级肺动脉扩张，肺淤血。,LA enlargement with straightening of the left heart border,-Double density,Signs of pulmonary overload include:,(1)prominence of pulmonary arteries,(2)enlargement of RV,and(3)evidence of CHF(eg,interstitial edema with Kerley B lines).,-,Normal Cardiac Shadow,Mitral Stenosis,-,LA border is prominently convex,实验室和其他检查,Imaging Studies,二、心电图,Electrocardiogram,“二尖瓣型P波”右心室肥厚,an enlarged left atrium is signified by a broad notched P wave,which is most prominent in lead II,with a negative terminal force in V1.,-With severe pulmonary hypertension,right axis deviation and RV hypertrophy can be seen.,-Atrial fibrillation is a common but nonspecific finding in MS.,三、超声心动图,Echocardiography,可确定和估测严重程度。二维超声心动图可显示狭窄瓣膜的形态和活动度，并测二尖瓣口面积,。,Confirm/severity,.,the most sensitive and specific noninvasive method,。,Left atrial size and the mitral area can be measured.The gradient and pulmonary artery pressure can be estimated.,color doppler can evaluate the transvalvular gradient,pulmonary artery pressure,and accompanying MR,四、心导管检查,Cardiac catheterization,考虑介入或手术治疗时，应经心导管检查同步测定肺毛细血管压和左心室压。,Increased left atrial or pulmonary capillary wedge pressure(PCWP),-Increased left atrial or PCWP to left ventricular pressure gradient,诊断,Diagnosis,诊断：1.心尖区有隆隆样舒张期杂音伴X线或心电图示左心房增大，2相关临床表现,3.,超声心动图检查可确诊。,If a low-pitched,rumbling diastolic murmur over the apex,an enlarged left atrium by ECG.Comfirm and severity by Echo,we can diagnose the mitrial stenosis.,鉴别诊断,Differential diagnosis,1、先天性心脏病（如室间隔缺损）,Congenital heart disease.,2、Austin-Flint杂音：见于严重主动脉瓣关闭不全。,Austin-Flint murmur3、左房粘液瘤：瘤体阻塞二尖瓣口,Left atrial myxoma.,并发症,(Complication),一、心房颤动(atrial fibrillation),可为患者就诊的首发病症。房性期前收缩常为其前奏。初起为心房扑动和颤动，之后转为慢性心房颤动。可使心排血量减少20%。,Loss of atrial contraction with the development of Afib,cardiac output by 20%.Since cardiac output is related to the heart rate,Afib with a rapid ventricular response,diastolic filling time and further compromises cardiac output.,up to 40%of pts.,二、急性肺水肿(acute pulmonary edema),为重度二尖瓣狭窄的严重并发症。,It is critical,complication of MS.,三、血栓栓塞 (thrombus embolism),心房颤动、大左心房（直径55mm）、栓塞时或心排血量明显降低为循环栓塞的危险因素。,20%of pts,at high risk for embolization are those aged over 35,those with Afib and a low cardiac output,and those having a large LA appendage.,肺动脉栓塞、外周动脉和内脏动脉栓塞。,四、右心衰竭 (right ventricular failure),五、感染性心内膜炎 (infective endocarditis),六、肺部感染 (pulmonary infection),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,治疗(,MS-Treatment),一、一般治疗,Nonspecific treatment预防风湿热复发,RF prophylaxis,、预防感染性心内膜炎,bacterial endocarditis.,.,prophylaxis,、避免剧烈体育活动,Avoid strenuous exercise,、呼吸困难者应限体力活动，限制钠盐摄入，口服利尿剂,。Limit exercise,Low sodium diet,and,Diuretics,二、并发症的处理,Treatment of complication,（一）大量咯血镇静剂，利尿剂,Expectoration of blood:Sedative and,Diuretics,（二）急性肺水肿,Acute pulmonary edema:the same treatment acute heart failure.,（三）心房颤动控制心室率，恢复和保持窦性心率，预防血栓栓塞,Afib,:,Rate control:,Digitalis.Beta-blocker.Calcium channel blocker,preventing thrombus formation:Anticoagulation,二、并发症的处理,Treatment of complication,(四）预防栓塞,preventing thrombus formation:,Anticoagulation,（五）右心衰竭限制钠盐摄入，应用利尿剂和地高辛,Right heart failure,:,Limit sodium,Diuretics,and,digitalis.,三、介入和手术治疗,Interventional treatment,（一）经皮球囊二尖瓣成型术,Balloon valvulotomy:,It most commonly is used in young pts without extensive valvular calcification,in pregnant women,and in pts who are unfavorable operative candidates.,（二）闭式分离术,Closecommissurotomy,（三）直视分离术,Open commissurotomy,（四）人工瓣膜置换术,Mitral valve replacement,performed if leaflets are immobile or heavily calcified,Percutaneous Transluminal,Mitral Valvuloplasty,二尖瓣关闭不全,(,Mitral Regurgitation/Insufficiency),定义,二尖瓣关闭不全(MR)是指由二尖瓣装置异常引起左室到左房血液的反流.,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 MR.,Etiology and Pathology（,病因病理）,多病因疾病.,包括器质性及相对性关闭不全.,根据其急慢性常见原因为：,慢性 急性,一、Chronic MR,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 MR,Infective,endocsrditis,Calcification ofmitral,ring and,subvalvular,(,二尖瓣环及环下区钙化,),Rupture of,chordae,tendineae,(unknown cause),LV enlarged significantly(,左室显著扩大,),Else,二、Acute MR,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,急性二尖瓣关闭不全,收缩期左室射血返流至左心房,左室，左房容量负荷剧增因急性左室扩张有限，左室心博量,增加不足以代赏反流量,左室舒张末期压力急剧升高 ,前向心博量和心排血量明显下降,肺淤血或急性肺水肿,肺动脉压急剧增高，右心室衰竭,慢性二尖瓣关闭不全,左室舒张末期,容量增加,持续的严重过,度负荷,左室舒张末期,压力和左房压,明显升高,肺淤血,肺动脉高压和,右室衰竭,左房顺应,性增强,左房增大,左房压、左室,舒张末期压不,致明显升高,左室收缩期,排血入低压,左房，利于,排空,左室心搏量增加,不出现,肺淤血,Acute MR,Chronic MR,Lung edema with normal heart size,Diffuse dilatation of the heart,临床表现,(,Clinical situation),一、症状,(,Symptoms,),（一）急性 劳力性呼吸困难 (Exertional dyspnea)急性左心衰竭 (acute left-sided heart failure),（二）慢性 早期可无症状，突出症状是疲乏无力 (Fatigue),晚期心力衰竭的症状。,二、,体征,（一）急性,心尖搏动为高动力性。第四心音常见。非全收缩期杂音，低调，呈递减型。,（1）Palpation may show thrill(vibration)over the heart.（2）A stethoscope may reveal a distinctive murmur in the heart.However,this murmur may be absent in some cases of acute mitral regurgitation.,（3）If fluid backs up into the lungs,there may be crackles heard in the lungs.Blood pressure is usually normal.,（二）慢性,1、心尖搏动 高动力型，向左下移位,2、心音 第一心音减弱，可闻及第三心音。二尖瓣脱垂时可有收缩中期喀喇音。,3、心脏杂音 全收缩期吹风样高调一贯型杂音，在心尖区最响。可向左腋下和左肩胛下传导。腱索断裂时杂音可似海鸥或音乐性,S1 Diminished,S3,A high-pitched blowing holosystolic murmur is common.,-the intensity of the murmur does not correlate well with the severity of the MR.,-A 3rd heart sound indicates a large LV filling volume,and its prevalence increases with increasing severity of the MR,Imaging Studies,一、,Chest radiography,Acute:,also show fluid in the lungs or prominent pulmonary veins.,Chronic:left atrial enlargement,LV dilatation.,Severe show,pulmonary edema.,Electrocardiogram,Acute:,usually shows a normal sinus rhythm but may show,arrhythmias,(abnormal heart rhythms)such as,atrial fibrillation,.,Chronic:,左心房增大，部分有左心室肥厚和非特异性,ST-T,改变，心房颤动常见。,Acute MR,Chronic MR,Lung edema with normal heart size,Diffuse dilatation of the heart,三、超声心动图,ECHO,脉冲多普勒超声和彩色多普勒血流显像可于,二尖瓣心房侧和左心房内探及收缩期高速射,流。可证实瓣膜病变的性质和程度。,Confirm the diagnosis,The,mitral,valve can be seen and the,regurgitant,jet visualized.The left atrium and ventricular sizes can be assessed,半定量反流程度测定：,轻度反流：最大射流面积,8 cm,2,四、,放射性核素心室造影,判断左心室收缩功能，评估反流程 度。,五、,左心室造影,为半定量反流程度的“金标准诊断和鉴别诊断,诊断（,Diagnosis,）,：,急性：1.有二尖瓣脱垂，感染性心内膜炎，AMI,创伤等病因。2.有急性心力衰竭的表现。3.心尖区有典型收缩期杂音。,慢性：1.有慢性心力衰竭的表现.2.心尖区有典型杂音伴左心房，左室增大.3.确诊有赖超声心动图。,Diagnosis:typical murmur at the apex,enlarged left atrium.,LV dilatation,.ECHO can confirm the diagnosis,.,鉴别诊断（,Differential diagnosis,）,：,一.三尖瓣关闭不全,在胸骨左缘第4、5肋间最清楚，伴有颈静脉收缩期搏动 和肝收缩期搏动。,二.,室间隔缺损 ；,在,胸骨左缘第4、5、6肋间最清楚，不向腋下传导，常伴有胸骨旁收缩期震颤。,三.胸骨左缘收缩期喷射性杂音,Complication,心房颤动(,atrial fibrillation),感染性心内膜炎(infective endocarditis),体循环栓塞(general circulation embolism),心衰 Heart failure,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,MR-Treatment,一、Acute:,1.Hospitalization may be required for diagnosis and treatment of severe symptoms.The goal of treatment is to control the symptoms.Emergency surgery may be necessary if acute regurgitation is severe,usually resulting from endocarditis(valve infection),heart attack,or ruptured cordae(one of the supporting structures of the mitral valve).,MR-Treatment,2.(1),Antibiotics may be prescribed if there is a bacterial infection.(2)Anti-arrhythmics(drugs that regulate the heart rhythm)may be needed to control irregular rhythms.(3)Vasodilators(drugs that dilate the blood vessels)reduce the workload of the heart.(4)Digitalis may be used to strengthen the heartbeat and diuretics(water pills)to remove excess fluid in the lungs.,MR-Treatment,3.,Anticoagulants or antiplatelet medications(blood thinners)may be used to prevent clot formation if atrial fibrillation is present,because atrial fibrillation increases the chances of clot formation.However,this treatment is primarily used for chronic mitral regurgitation.,急性,二,、,Chronic MR,Asymptomatic:Monitor Symptoms.Echo,2.(1),Low sodium diet.(2)Preload reduction,Diuretics.(3),Afterload,reduction Vasodilators,Nitroprusside,generic,ACE inhibitors,Hydralazine,generic,Digoxin,generic.,SBE prophylaxis,3.,Surgical:,Symptomatic:severe,mitral,regurgitation,Class III,IV.EF50ml/m,LVEF20mmHg之前手术治疗。,（2）、二尖瓣修复术,适应症为非风湿热、非感染性和非缺血性病因者，如二尖瓣脱垂。,预后,年龄50岁，有明显收缩期杂音和二尖瓣反流，左心房、左心室增大者预后较差。,Aortic Valve Disease,主动脉瓣疾病,主动脉瓣狭窄,Valvular Aortic Stenosis,Aortic stenosis(AS)is the obstruction of blood flow across the aortic valves because of valvular damage.,Aortic Stenosis,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,2.Congenital bicuspid valve(,先天性二叶瓣,),3.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,Frequency:发生率,-The etiology of AS in those aged 30-70 yrs can be rheumatic disease or calcification of a congenital bicuspid valve.30-70岁主动脉狭窄的病人常为风湿病或先天性。,-70 yrs,degenerative calcification is the primary cause of AS.,70岁主动脉狭窄的病人常为退性性老年钙化。,Among people older than 75 years,3%have critical AS.,在,70岁主动脉狭窄的病人中，,3%为严重主动脉狭窄,-Among children,75%of cases of AS are in males.,在儿童中，,75%主动脉狭窄的病人为男性。,A,Normal aortic valve,B,Congenital AS,C,Rheumatic AS,D,Calcified AS,E,Calcified senile AS,病理生理,Pathophysiology of Aortic Stenosis,成人主动脉瓣口3.0cm。当瓣口面积减少一半时，收缩期仍无明显跨瓣压差。瓣口1.0 cm时,左心室收缩期明显升高，跨瓣压差显著。,Related to pressure changes,valve obstructed,LV pressure,LV hypertrophy,LA enlarges,decreased cardiac output,ASAfterloadingLVhypertrophyLVED,Myocardial ischemia,Myocardial contractility,Heart failure,LA amplification,PAP PCP,Lung congestion and edema,严重主动脉瓣狭窄引起心肌缺血机制：,室壁肥厚、收缩压增高及射血时间延长,心肌毛细血管密度相对减少,舒张期腔内压增高压迫心内膜下冠脉,左室舒张末压增高、冠脉灌注压下降,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,临床表现(,Clinical situation),（一）,呼吸困难,劳力性呼吸困难，夜间呼吸困难，端坐呼吸，急性肺水肿。,Mechanisms of Dyspnea：LVH,diastolic dysfunction，Progressive LV dilation and contractile failure systolic dysfunction,临床表现(,Clinical situation),（二）,Anginal Chest Pain inAortic Stenosis,心绞痛,Mechanisms：Increased wall stress,increased myocardial O,2,demand,exceeds ability to coronary flow to meet demand,Associated coronary artery disease,临床表现(,Clinical situation),（三）：,Syncope in Aortic Stenosis,晕厥或接近晕厥,Mechanisms：(1)Fixed cardia coutput:Vasodilation(exercise,vagal stimulation,drug induced),inability to augment CO,drop in cerebral perfusion pressure.,(2)Heart block:Ca,+,deposits in aortic ring encroach upon conduction tissue,(3)Ventricular arrhythmias,(LVH,ischemia),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,实验室和其它检查,Imaging Studies:,一、,Chest x-rays,may show cardiac enlargement,more severe stages of AS,signs of LAE,PA enlargement,Rt-sided enlargement,and pul.congestion are evident,.,二、,ECG:,LVH with repolarization changes“strain pattern”,Aortic Stenosis,-rounded LV border,(LVH),-prominent proximal,ascending aorta,(post-stenosis dilatation),Imaging Studies,三、超声心动图,为明确诊断和判定狭窄程度的重要方法。二维超声心动图有助于显示瓣叶数目、大小、增厚、钙化，交界处融合、瓣口大小和形状、瓣环大小。连续多普勒测定可计算出平均和峰跨膜压以及瓣口面积,。,Echo:Aortic valve thickening and restricted motion,Doppler:Gradient across aortic valve