Valvular Heart Disease Aortic Regurgitation主動(dòng)脈瓣返流瓣膜性心臟病

AorticregurgitationDrHusainTayibAorticregurgitation

Etiology

*Anyconditionsresultinginincompetentaorticleaflets

_Congenital

BicuspidAV_AortopathyCysticmedialnecrosisCollagendisorders(.MarfanSyn.]Ehler-DanlosOsteogenesisimperfectaPseudoxanthomaelasticum_Acquired*Rheumaticheartdisease*Dilatedaorta[hyperte.]*Degenerative*Connectivetissuedisorder_Ankylosing

spondylitis,_Rheumatoidarthritis,_Reiter’ssyndrome,_Giant-cellarteritis)*Syphilis(chronicaortitis)*AcuteAR:,_Infectiveendocarditis,_Trauma_DissectinganeurysmAorticregurgitationAorticregurgitationAorticDissectionBicuspidAVMarfansyndromeAorticregurgitationPathophysiologyLVDOL….LVdilatation….IncreasedSV…..WidePP…..LVH…DilatedLA….IncreasedLVEDP……LAPrise…..Pulmonarycongestion….PH….RVH……RVFChronicARElevatedLVend-diastolicpressureandvolumeDilatationandeccentrichypertrophyoftheLVIncreasedstrokevolumeLeftventricularEF

normalGraduallyLVpreloadandafterloadbothincreasedUltimately,adaptivemeasuresfail.LVfunctiondeterioratesEnd-diastolicvolumerisesfurther(thelargestheart)

Myocardialischemia

DeclineinforwardstrokevolumeandEFSymptoms

_Dyspnea,orthopnea,PND

_Chestpain.Nocturnalangina>>exertionalangina{

diastolicaorticpressureandincreasedLVEDPthus

coronaryarterydiastolicflow}*Withextremereductionsindiastolicpressures{e.g.<40}mayseeangina

MildtomoderateAR:

*Oftenasymptomatic*Palpitation

SevereAR:Aorticregurgitation

_Quincke’ssign:capillarypulsation_Corrigan’ssign:_Waterhammerpulse_Bisferienspulse(AS/AR>AR)_DeMusset’ssign:systolicheadbobbing_Mueller’ssign:systolicpulsationofuvula

_Durosier’ssign:femoralretrogradebruits_Traube’ssign:pistolshotfemorals_Hill’ssign:BPLowerextremity>BPUpperextremityby_>20mmHg-mildAR_>40mmHg–modAR_>60mmHg–severeARAorticregurgitationPeripheral

Signs

CentralSignsofSevere

Apex:

_Enlarged_Displaced_Hyper-dynamicLforcible

nonsustained_PalpableS3_Austin-FlintmurmurAorticdiastolicmurmur_Lengthcorrelateswithseverity{chronicAR}_InacuteARmurmurshortensasAorticDP=LVEDP_InacuteAR-mitralpre-closureAorticregurgitationAUSCULTATIONMurmur:high-pitched,blowing,decrescendodiastolicmurmur,heardbestinthethirdintercostalspacealongtheleftsternalborder(holodiastolicinsevereAR)Whenthemurmurissoft,itcanbeheardbestwiththediapgm

hraofthestethoscopeandwiththepatientsittingup,leaningforward,andwiththebreathheldinforcedexpiration.10S1S2S1Widenedpulsepressure

systolic–diastolic=pulsepressure

_PhysicalexaminationAorticregurgitation

Amid-systolicejectionmurmurfrequentlyaudibleinisolatedARFlintmurmur,asoft,low-pitched,rumblingmid-diastolicmurmurprobablyproducedbythediastolicdisplacementoftheanteriorleafletofthemitralvalvebytheARstreamnotduetohemodynamicallysignificantmitralobstruction11

CommonMurmursandTiming

,_SystolicMurmurs_Aorticstenosis_Mitralinsufficiency_Mitralvalveprolapse_TricuspidinsufficiencyDiastolicMurmurs_Aorticinsufficiency_MitralstenosisS1S2S1AorticregurgitationAorticregurgitationInvestigations:*ECG:-LVH+Tinversion*ChestXR:-_Cadiacdilatation_Aorticdilatation_Pulmonarycongestion*ECHO:-_DilatedLV_HyperdynamicLV_FlutteringAML_Dopplerdetectsreflux*CardiacCatheterization:-_DilatedLV_AR_DilatedaorticrootAorticregurgitationChestXR

PAviewAorticregurgitationECGLVHAorticregurgitationCW-dopplerARAR+ASCFMARARARAssessingseverityofAR*AssessseveritybyimpactonperipheralsignsandLVperipheralsigns=severityLV=severityS3Austin–FlintmurmerLVHradiologicalcardiomegalyAorticregurgitationNaturalhistory:*Asymptomatic%/YNormalLVfunction{--goodprognosis}_ProgressiontosymptomsorLVdysfunction<6_ProgressiontoasymptomaticLVdysfunction<3.5_5-yearsurvival75% <0.2 _SuddendeathAbnormalLVfunction_Progressiontocardiacsymptoms25*Symptomatic{poorprognosis_Mortality>10%

BonowRO,etal,JACC.1998;32:1486.TX:MedicalSurgeryBEFORELVdysfunctionAorticregurgitationAorticregurgitationManagement:

*Medical:_Vasodilator{ACEIs}_Diureticsforpulmonarycongestion_ProphylaxisagainstIE_Treatmentofunderlinecausee.g.IE,Syphilis

*Surgical:_AVreplacementMechanicalorBioprosthesis_AorticrootreplacementfordilatedAroot,{e.g.Syphilis,