心瓣膜病課件

心瓣膜病2

Definitionreferstovalvularstenosisanddeficiencyduetostructureorfunctionabnormalitiesofsingleormultiplevalves(includingvalvecusp,valvering,chordaetendineaeorcolumnaepapillares)causedbyallreasons(includinginflammation,mucousdegeneration,regressivechange,congenitaldeformity,ischemicnecrosis,trauma,etc.)瓣膜結(jié)構(gòu)3Pathogeny1.rheumatic

mostcommon，almost80%

age<40，female>male

causedbyrepeatedrheumaticfever

2.non-rheumatic1)congenitaldeformity2)calcificdegeneration：mostcommoninelder

andincreasing3)trauma,ischemicnecrosis,etc4Epidemiology1.rheumaticfever

home：incidence

rate32~64/100,000“8-5”research：20/100,000

PanYu：20/100,000

countryinSiChuanprovince：62/100,000

USA：primaryrheumaticfever0.5/100,0002.rheumaticheartdisease

home：

prevalencerate1.99‰

USA：

prevalencerate0.05‰5RateofInvolvedvalveinrheumaticvalvulardiease

clinic

anatomyMitralvalve95%~98%100%Aorticvalve20%~35%48.5%Tricuspidvalve5%12.5%Pulmonaryvalve

<1%6.5%CombinedvalvularDisease20%~30%6mitralstenosis,MS

（二尖瓣狹窄）7ⅠPathogenyandPathology1.rehumaticheartdisease：mostcommon，20~40yrfemaleaccountfor2/3

lastfor2yearstoformtheobviousstenosisatleast

basicchange：inflammatoryadhesionofvalve

①Diaphragmtype

②Funneltype

calcificationofvalveringandsubvalvualrstructure

enlargementofleftatrium，muralthrombusofleftatrium2.others：Congenitaldeformity,connectivetissuedisease,etc8MitralStenosis

4～6cm2（normal）1.5～2.0cm2(mild)1.0～1.5cm2(morderate)<1.0cm2(severe)9Ⅱ

pathophysiology10Ⅱpathophysiology

≦2.0cm2（mild）（DM）（compensative）MS

bloodflow

LA

highpressure

getstuck<1.5cm2（moderate）

pulmonarypressure

pulmonarypulmonarycongestion

capillaryvenouspressureLAdalation（30-35mmHg）（hemoptysis）

pulmonary

pulmonaryatery

RVhypertrophy

edema

hypertension

（

hoarseness）

(leftHF)right

HF11ⅢClinicalmanifestation1.symptoms1)Dyspnea：earliest,

dyspneaonexertionorrest,paroxysmalnocturnaldyspnoea,orthopneaandacutepulmonaryedema

2)Haemoptysis：bloodinsputum;massivehaemoptysis;pinkfoamysputum;darkandthickmucoussputum.3)Cough：

4)Hoarseness：paralysisofleftrecurrentlaryngealnervecausedbyenlargedleftatriumorpulmonaryartery.

5)others：thromboembolism、rightHF

lowcardiacoutput：tired12ⅢClinicalmanifestation2.sign1)DM：rumbling,Diastolicthrill2)loudfirstsound，openingsnap3)enhancementofP2

，Grahamsteellmurmur4)Mitralface，Apicalapophysis

（children）5)LA、RV

dilation：“pearshape”（mitralvalvularheart）6)rightHF：L4-5diastiolcgallop13Ⅳ

Labandinstrumentalexam1.

Echocardiography

confirmationofdiagnosis2.ECGMitralPwave

rightventricularhypertrophy14左室長(zhǎng)軸切面左室短軸切面M型超聲15彩色多普勒血流頻譜多普勒16后前位片左側(cè)位片3.chestX-Ray：“pearshape”17ⅤDiagnosisanddifferentialdiagnosis1.diagnosis1)apicaldiastolicrumblingmurmur+LAdilation2)middleageorhistoryofrheumaticfever3)echocardiography4)excludetheotherreasonforapicaldiastolicrumblingmurmur18ⅤDiagnosisanddifferentialdiagnosis

2.differentialdiagnosis1)relativetricuspidstenosis(corpulmonale)2)relativemitralstenosis3)rheumaticvalulitis4)Austin-Flint

murmur5)LAmyxoma19Ⅵ

Complications1.Atrialfibrillation2.Acutepulmonaryedema：severemitralstenosis3.rightHF：mainlycauseofdeath4.infectiveendocarditis5.Lunginfection：common6.Thrombo-embolism：2/3forcerebralarteries20感染性心內(nèi)膜炎21左房血栓22左房血栓23Ⅶ

Treatment1.Compensationstage

preventtherelapseofrheumaticfever

benzathinepenicillin1200TU/m

preventtheinfectiveendocarditis

keepawayfromoverstrainandnervous，

limitthesodiumintake2.Decompensationstage

digitalis、diuretics、vasodilations

etc

forcomplication243.interventionandsurgicaltreatmentPercutaneousballoonMitralvalvuloplasty(PBMV)indication：①Elasticmitralvalve②oldandsevereCHD③severediseaseoflung,kindeyandtumororrefusetosurgicaltreatment④pregnancyanddyspnea⑤restenosisaftervalvotomyvalvotomy

closed

directvisionProstheticvalvereplacement

indication：①Severecalcificationordeformityofvalveorsubvalvularstructure,notsuitableforvalvotomy

②MScombinedwithMI25ⅧPrognosis

Lieon：1.thedegreeofthestenosisandheartdilation2.combinewithmultiplevalvularlesion3.possibilityofsurgery4.controloftherheumaticactivity5.treatmentofthecomplicationCauseofdeath：HF（62%），thromboembolism（22%）

infectiveendocarditis（8%）26Ⅸ

Prevention1.primaryprevention

earlydiagnosisandtherapyisthekeytothefirstonset2.secondaryprevention1)firsttimeofrheumaticfeverbutnomyocarditis，preventionfor5years，children18~20yearsold2)firsttimeofrheumaticfeverandwithmyocarditis，preventionuntil25yearsold3)rheumaticvalvulardisease，preventionuntil50yearsold27mitralincompetence,MI

（二尖瓣關(guān)閉不全）28ⅠPathogenyandPathology

1.chronic

1)rheumaticheartdisease：common，moreinfeamle

deformationofvalvesandchordaetendineaeduetochronicinflammation2)mitralvalveprolapse

mucousdegenerationofvalves，flaboffibroustissue，valvesandchordaetendineaelengthen，euchromosomedominantheredity3)CHD：MI，

insufficiencyofmusculuspapillary4)calcificationofmitralvalveringandsubvalvering5)others：IE、congenitaldeformity、obstructivemyocardiopathy29ⅠPathogenyandPathology2.acute1)ruptureofchordaetendinea2)ruptureorlesionofvalves3)ischemia、necrosisorruptureofmusculuspapillaryduetoAMI4)trauma5)other：lesionofprostheticvalve30Ⅱ

pathophysiology

（SM）

MI

bloodflowregurgitate

LAhighpressurefromLVtoLA

high

pulmonarypressure

pulmonarycongestion

venousandcapillaryLAdilation

pulmonarypressureRVhypertrophy

rightHF

pulmonaryedema（leftHF）LVhighpressureLVhypertrophy31Ⅱ

pathophysiology1.chronic

VolumeloadinLAandLVincreased,compensationstageofLVislong，LAandLVdilateobviously，leftHFoccurslate，butonceithappen，itprogressesrapidly.2.acute

VolumeloadinLAincreaserapidlyinearlystage，alsoisthepressure，usuallyitdevelopstoleftHFandpulmonaryedema.32ⅢClinicalmanifestation

1.symptoms

1)dyspnea：dyspneaonexertion,paroxysmalnocturnaldyspnoea,orthopnea,acutepulmonaryedemaandcardiacshock(acute)2)lowcardiacoutput：tired3)rightHF：33ⅢClinicalmanifestation2.sign

1)systolicmurmurinmitralvalvearea：

withradiationtoleftaxilla(anteriorvalve)orleftsternum(posteriorvalve)2)Midandlatesystolicclickmurmur（Mitralprolapse）3)Weakenedfirstsound、enhancedP2，S3canbeheardatapicalarea.

4)cardiacdilatation，andmovetoleftanddownside5)apicalimpulse6)rightHF：L3-4diastolicgallop34Ⅳ

Labandinstrumentalexam1.

echocardiography：diagnosis

mild：<4cm2moderate：4~8cm2severe：>8cm2mitralprolapse：valveprotrudeintoLAinsystolicphase

M-US:“hammockshape”

ruptureofchordaetendineae：flail-likechange2.ECG：sinustachycardia、LA、LV

dilation3.chestX-Ray：acute；chronic4.radionuclideventriculography

5.leftventriculography

35二尖瓣關(guān)閉不全四腔心切面36MI3738ⅤDiagnosisanddifferentialdiagnosis1.diagnosis1)typicalsystolicmurmurinapicalarea2)LA、LVdilation（chronic）3)relatetoclinic（onset,age,LAdilationornot)toconfirmthecause

4)echocardiographytoconfirmation39ⅤDiagnosisanddifferentialdiagnosis

2.

differentialdiagnosis

systolicmurmurinapicalarea：1)tricuspidincompetence

withoutradiationtoleft；wheninspirate；jugularveinimpulse2)interventricularseptaldefect3)aorticorpulmonarystenosis40Ⅵ

Complications1.chronic

similartoMS，butlater

suddendeathinpatientwithmitralprolapse

2.acute

leftHFinearlystage41Ⅶ

treatmentInternaltherapy

①keepawayfromoverstrainandnervous，preventfrominfectionpreventfromhemolyticstreptococcusinfectionandinfectiveendocarditis②vasodilation：ACEI

acuteMI:sodiumnitroprussiateandIABPbeforesurgery③diuretics④digitalis⑤anticoagulantSurgicaltherapy：Prostheticvalvereplacementandrepair42ⅧPrognosis

compensatorystage

ofchronicincompetenceislong，itcanlastfor20years，butonceitdeveloptodecompensation，itexacerbaterapidly，itsmortalityisveryhigh.

mostoftheacuteonsetpatientdiefromleftHF.43Aorticincompetence,AI

（主動(dòng)脈瓣關(guān)閉不全）44ⅠEtiologicalfactorandpathology1.chronic

1)lesionofvalves：①rheumaticheartdisease：mostcommon

②infectiveendocarditis

③congenitaldeformity：Bicuspidaorticvalve

interventricularseptaldefectwithmonovalveprolapse

④aorticvalveprolapse：

mucoiddegenerationofvavles

⑤Ankylosingspondylitis2)dilationofaortaascendens（root）：

Syphiliticaortitis

Marfansyndrom,atherosclerosis

ofaortaascendens45ⅠEtiologicalfactorandpathology

2.acute

1)valveslesion：infectiveendocarditis

ruptureaftersurgeryofaorticvalve

truama2)acutedilationofaortaascendens：

separationofascendingaorticdissection

Marfan

syndrom

atherosclerosis

ofaortaascendens46ⅡPathophysiology

(DM)Bloodinaortaregurgitates

LVEDV↑toLVindiastolicphaseLVEDP↑

diastolicpressure↓

pulsepressure↑LVhypertrophyLApressure↑

pulmonarypressurevenousandcapillary↑

pulmonaryedema

（leftHF）Peripheralvesselsigns

：Water-hammerpulse

capillarypulsationsignPistolshotDuroziezsignDe-Mussetsign47Ⅲ

Clinicalmanifestation

1.symptoms1)chestpain（angina60%）

2)

palpitation,

polypnea3)other：strongpulsatoryfeelingofheadandneck，dizzinessorvertigo4)Advancedleftventriculardysfunction48Ⅲ

Clinicalmanifestation2.sign

1)apexbeatmovetolowandleftside，heavingapeximpulse，bootlastheart2)diastolicmurmurcanbeheardattheaorticvalveauscultationarea3)Austin-Flintmurmur4)Peripheralvesselsigns(chronic)：Water-hammerpulse，capillarypulsationsign，Pistolshot，Duroziezsign，De-Mussetsign5)usuallythepulsepressureisnothighinacuteonset49Ⅳ

Labandinstrumentalexamination1.echocardiography

todiagnoseandjudgethecause，decidethedegreeoftheregurgitation50AI51Ⅳ

Labandinstrumentalexamination2.ECG

3.chestX-Ray

chronic：aorticheart

acute：normalrange

orpulmonarycongestion

4.radionuclideventriculography

5.aorticangiography6.MRI52Ⅴ

Diagnosisanddifferentialdiagnosis1.Typicaldiastolicmurmurinaorticvalveauscultationareaandperipheralvesselsigns2.ECG：especiallydopplerechocardiography

3.DifferentiatetheGraham-Steellmurmur53ⅥComplications1.infectiveendocarditis2.Heartfailure3.arrythmia:ventricularⅦ

Prognosis

dependsonetiologicalfactor,degreeofregurgitation,complications.54Ⅷ

TreatmentInternaltherapy①keepawayfromoverstrainandnervous，preventfrominfectionpreventfromhemolyticstreptococcusinfectionandinfectiveendocarditis②vasodilations③diuretics④digitalis⑤anticoagulantsSurgicaltherapy（Prostheticvalvereplacement、

repair

andaorticrootreplacement）55AorticStenosis,AS

（主動(dòng)脈瓣狹窄）56ⅠEtiologicalfactorandpathology1.rheumaticheartdisease：nosimplecauseadhesionaftervalvulitis，valveorificeopeningislimited主動(dòng)脈瓣狹窄57ⅠEtiologicalfactorandpathology

2.congenitaldeformity：valvehypoplasia，

Bicuspidvalve>1/2，thenincrassationandcalcification，commoncause

3.Retrogressivevalvecalcificationinoldpatientscommonly>65yearsold

usuallywithcalcificationofmitralvalvering58Ⅱ

Pathophysiology

ASconstrictionofLV↑resistance↑

transvalvularpressuregradient↑

LVEDP

↑

LVhypertrophy，LA

contractcompensatory

tokeepnormalvalveorificearea

strokevolumedescendto?ofnormality

cardiacoutput↓

myocardialanoxiaOxygenconsumption↑Myocardialoxygensupple↓59Ⅲ

Clinicalmanifestation1.symptoms

1)Dyspneaonexertion

2)Anginapectoris60%

3)Syncope

orAmaurosis：occursin1/3patientswithsymptoms

Mostlyoccursintheupright,movement,orimmediatelyafterexercise4)

others：acutepulmonaryedema、suddendeath60Ⅲ

Clinicalmanifestation2.signs1)

apexbeatmovetolowandleftside，heavingapeximpulse，2)systolicmurmurinaorticarea，maybewiththrill3)S2inaorticarea，

paradoxicalsplitting4)Lowsystolicpressure,decreasedpulsepressure61Ⅳ

Labandinstrumentalexamination1.echocardiography

todiagnoseandjudgethecause，decidethedegreeofthestenosis62Ⅳ

Labandinstrumentalexamination

2.ECG3.ChestX-Ray4.Cardiaccatheterization

gradient