心臟瓣膜病幻燈片

ValvularHeartDisease心臟瓣膜病心臟瓣膜病19心臟瓣膜病

是指心瓣膜及瓣下裝置由于炎癥、變性、粘連、缺血性壞死、創(chuàng)傷、老化或鈣質(zhì)沉著及先天性發(fā)育異常等原因，使單個或多個瓣膜發(fā)生急性或慢性的狹窄或關(guān)閉不全，導(dǎo)致前向血流障礙和/或返流的一組疾病。臨床上最常受累的為二尖瓣，其次為主動脈瓣。風濕性心臟病

簡稱風心病，仍是我國主要的心臟病，是風濕性炎癥過程所致瓣葉損害。根據(jù)人群發(fā)病率調(diào)查已有下降趨勢。心臟瓣膜病19Mitralvalvedisease

二尖瓣疾病心臟瓣膜病19Mitralstenosis(MS)

二尖瓣狹窄心臟瓣膜病19EtiologyandPathology

（病因和病理）Rheumaticheartdisease(風濕性心臟病)Congenitalmalformation(先天性畸形)Senilemitralannulusandsubvalvularcalcification(老年人二尖瓣環(huán)及環(huán)下區(qū)鈣化)心臟瓣膜病19Pathophysiology(病理生理)Thecross-sectionalareaofthemitralvalveorifice(瓣環(huán)口面積）Normaladults4-6cm2MildMS≤2cm2ModerateMS≤1.5cm2SevereMS≤1.0cm2心臟瓣膜病19TheeffectonLAandcardiacoutputofMSMildMS：LA壓力輕度升高，心排血量正常SevereMS：跨瓣壓差增大(20mmHg)→LA壓力升高（25mmHg)；休息時心排血量正常或減少Theeffectonthepulmonarycirculationandrespirationofelevatedleftatriumpressure心臟瓣膜病19

LA

→PVP、PCP→lungcongestion/pulmonaryedema

pulmonaryarteryintimahyperplasiaandthickening

（肺動脈內(nèi)膜增生肥厚）

PAP（肺動脈壓升高）

Rightheartfailure（右心衰竭）心臟瓣膜病19Remarks(備注)PAP：肺動脈壓PCP：肺毛細血管壓PVP肺靜脈壓心臟瓣膜病19Clinicalsituation(臨床表現(xiàn))一、Symptom(中度狹窄始出現(xiàn)癥狀)Exertiondyspnea(勞力性呼吸困難)Hemoptysis(咯血)

支氣管靜脈壓↑破裂出血肺梗死肺水腫心臟瓣膜病19Hoarseness（聲嘶）Cough(咳嗽）

LA增大壓迫左主支氣管，支氣粘膜淤血水腫，易致感染擴大的LA、肺A壓迫喉返N心臟瓣膜病19Clinicalsituation二、PhysicalSign(體征)Mitralfacies(二尖瓣面容)S1↑，可聞及OS(開瓣音)CardiacapexDM(心尖區(qū)舒張期雜音），oftenaccompanyingdiastolicthrill(舒張震顫）RV↑，P2excessive(亢進)，RelativeSMofTI(相對性三尖瓣關(guān)閉不全收縮期雜音)心臟瓣膜病19Laboratoryexamination

(實驗室檢查)X－Ray二尖瓣型心：左房右室大，主動脈結(jié)縮小，肺動脈擴張，肺淤血ECGPⅡ>0.12s,RV1↑,電軸右偏，心房纖顫，粗f波

Echocardiogram(超聲心動圖)：是確診、定量MS的可靠方法心臟瓣膜病19M型：二尖瓣前后葉同向運動二維：狹窄瓣膜形態(tài)結(jié)構(gòu)，瓣口面積，房室大小連續(xù)多普勒：測定血流速度、跨瓣壓差Cardiaccatheterization(心導(dǎo)管術(shù))

測定肺毛細血管壓和左室壓，確定跨瓣壓差，明確狹窄程度心臟瓣膜病19DiagnosisandDifferentialdiagnosis(診斷和鑒別)Diagnosis心尖區(qū)DM＋LA擴大及實驗室檢查可診斷，超聲有確診價值Differentialdiagnosis二尖瓣口血流增加AustinFlint雜音左房粘液瘤：隨體位改變的DM心臟瓣膜病19Complication（并發(fā)癥）一、Atrialfibrillation(心房纖顫)見于5%以上的患者；房顫使心排量下降20%，常是體力活動明顯受限的開始二、Acutepulmonaryedema(急性肺水腫)為重度MS最嚴重的并發(fā)癥及致死原因三、Embolism(栓塞)80%有房顫、大左房（D﹥55mm)；2/3為腦栓塞，也可有周圍及內(nèi)臟栓塞心臟瓣膜病19Complication（并發(fā)癥）四、Rightheartfailure(右心衰竭)五、Pulmonaryinfection(肺部感染)心臟瓣膜病19Prognosis(預(yù)后)無癥狀者可存活多年，一旦有癥狀至致殘平均7.4年死亡原因多為上述并發(fā)癥心臟瓣膜病19Therapy(治療)Generaltherapy(一般治療)：預(yù)防風濕熱及感染性心內(nèi)膜炎Hemoptysis(咯血)：減低肺靜脈壓力Atrialfibrillation：快速心室率時應(yīng)用洋地黃Rightheartfailure：以利尿為主心臟瓣膜病19Therapy(治療)Acutepulmonaryedema：處理同急性左心衰；注意二尖瓣狹窄時用正性肌力藥物不好，僅當房顫快速心室率時應(yīng)用Mechanictherapeutics(機械治療)MS：經(jīng)皮球囊二尖前瓣成型術(shù)；外科手術(shù)心臟瓣膜病19Mitralincompetence:MI

二尖瓣關(guān)閉不全心臟瓣膜病19EtiologyandPathology

（病因病理）Duringsystole,competence(關(guān)閉)ofmitralvalvedependontheintegrityofmitralstructureandfunction(includingleftletsofvalve,mitralannulus(瓣環(huán)),tendinouscords(腱索),papillarymuscle(乳頭肌)andLV.EveryabnormalitymayleadtoMI.心臟瓣膜病19一、ChronicMIRheumaticheartdisease:Theleftletsofmitralvalvefibrose,thicken,shortenandoftenaccompanyMSandaorticvalvediseaseMitralvalveprolapse(二尖瓣脫垂)CHD：Chronicischemia(缺血)orinfarction(梗死)leadtofibrosisandfunctionaldisorderofpapillarymuscle心臟瓣膜病19一、ChronicMI

Calcificationofmitralringandsubvalvular(二尖瓣環(huán)及環(huán)下區(qū)鈣化)InfectiveendocsrditisRuptureofchordaetendineae(unknowncause)LVenlargedsignificantly(左室顯著擴大)Else

心臟瓣膜病19二、AcuteMI

Ruptureofchordaetendineae(腱索斷裂)Endocarditisleadstotheleftletsofvalvedestruction(心內(nèi)膜炎致瓣葉毀損)Acutemyocardialinfarction(急性心肌梗死)Traumaresultsinruptureofthemitralvalvecomponent(創(chuàng)傷使二尖瓣器破裂)Ruptureofprostheticvalve(人工瓣膜開裂)心臟瓣膜病19PathophysiologyMI→LVEDV↑→LVhypertrophy→LVEDP↑↑,LA↑↑→LVfailure→Pulmonarycongestion→PAP↑→Rightheartfailure心臟瓣膜病19Clinicalsituation(臨床表現(xiàn))一、Symptom輕度MI可終身無癥狀，嚴重MI心排血量減少，感乏力、呼吸困難二、PhysicalSignHeavingapeximpulse(抬舉性心尖搏動)Cardiacsound：S1↓（重度MI），S2分裂，聞及S3Cardiacmurmur：從S1后立即開始，與S2同時終止的SM，可伴收縮期震顫，向右腋、右肩胛下區(qū)傳導(dǎo)；乳頭肌功能不全、腱索斷裂的雜音似海鷗鳴叫樣心臟瓣膜病19LaboratoryexaminationX－RayECGEchocardiogram二維超聲：可顯示二尖瓣的形態(tài)結(jié)構(gòu)，提供心室大小，明確病因彩超連續(xù)多普勒：可用于二尖瓣心房側(cè)探及收縮期射流，半定量返流量心臟瓣膜病19DiagnosisandDifferentialdiagnosis心尖區(qū)SM＋心房、心室增大，診斷MI可成立，確診有賴于超聲心動圖應(yīng)與以下情況相鑒別：Tricuspidincompetence（三尖瓣關(guān)閉不全）：胸左緣4、5肋間SM，可傳至心尖區(qū)，雜音吸氣時增強，伴頸靜脈收縮期搏動，RV↑↑VSD（室間隔缺損）心臟瓣膜病19Systolicejectionmurmurinleftborderofsternum生理性雜音功能性雜音主、肺動脈根部擴張左或右室流出道梗阻心臟瓣膜病19AtrialfibrillationInfectiveendocarditisEmbolismHeartfailureComplication心臟瓣膜病19Prognosis急性嚴重返流者，若不及時手術(shù)，極難存活慢性MI無癥狀期長，一旦發(fā)生左心衰竭，預(yù)后不良心臟瓣膜病19TherapyMedicaltherapy(內(nèi)科治療)PreventendocarditisandrheumaticfeverPatientswhoareasymptomaticandhavingnormalcardiacfunctionneedn’ttherapybutregularfollow-up(定期隨訪).Complicationarecuredinpatientswithcomplication.心臟瓣膜病19Surgicaltreatment

Prostheticvalvereplacement為主要手術(shù)方法，趨向早期手術(shù)有癥狀者應(yīng)在LVEF＜0.5，平均肺動脈壓＞20mmHg之前手術(shù)產(chǎn)生左室功能不全、LVEF0.3－0.5、年齡＞55歲、LVEDD≥80mm，已不置換瓣

Valvuloplastyofmitralvalve(二尖瓣整復(fù)術(shù))優(yōu)點：不需長期抗凝，LV功能恢復(fù)較好心臟瓣膜病19AorticValveDisease主動脈瓣疾病心臟瓣膜病19Aorticstenosis(AS)主動脈瓣狹窄心臟瓣膜病19EtiologyandPathologyRheumaticheartdisease：風濕性炎癥所致瓣膜交界處融合、瓣葉纖維化、鈣化，引起瓣葉狹窄畸形，多伴AI及二尖瓣損害Congenitalbicuspidvalve(先天性二葉瓣)Senilecalcific(degenerative)AS(退行性老年鈣化性主動脈瓣狹窄)：65歲老年人AS的常見原因，瓣葉主動脈面鈣化結(jié)節(jié)限制瓣葉活動心臟瓣膜病19PathophysiologyThecross-sectionalareaoftheaorticvalveorifice(瓣環(huán)口面積）Normaladult≥3.0cm2Thearea≤1.0cm2,LVSP↑,transvalvepressuregradientmanifest(跨瓣壓差明顯)心臟瓣膜病19AS→Afterloading↑→LVhypertrophy→LVEDP↑LAamplification↓PAPPCP↑↓LungcongestionandedemaMyocardialischemia↓Myocardialcontractility↓↓Heartfailure心臟瓣膜病19ClinicalsituationSymptomASTriplesyndrom(AS三聯(lián)癥)

Dyspnoea(呼吸困難):LungcongestionAngina(心絞痛)Causingby

Synocope(暈厥)cardiacoutput↓心臟瓣膜病19ClinicalsituationPhysicalsignCardiacsound:S1isnormal,S2isparadoxicalsplitting(逆分裂),S4maybeheardCardiacmurmur:：SMisheardonthesecondintercostalspace(肋間)ofrightborderofsternum,andradiatetocervicalpart(頸部),leftinferiorborderofsternumandcardiacapexaccompanyingthrillCardiacdilatation(心臟擴大)，SBPandpulsepressuredecrease心臟瓣膜病19LaboratoryexaminationX-Ray：心影可正常或稍大，晚期見肺淤血ECG：可有左室肥厚勞累征，及各種心律失常Echocardiogram：為確定、定量AS的重要方法Cardiaccatheterization：可根據(jù)左室-主動脈壓差計算瓣口面積心臟瓣膜病19DiagnosisandDifferentialdiagnosisDiagnosis

典型的收縮期雜音，易于診斷；多瓣膜病變提示風心病單純AS：根據(jù)年齡，應(yīng)考慮單葉瓣、二葉瓣膜及老年退行性變，確診有賴于超聲心動圖DifferentialdiagnosisAS應(yīng)與左室流出道梗阻性疾病鑒別心臟瓣膜病19ComplicationArrhythmia：10%可發(fā)生房顫、竇性心律失常、房室傳導(dǎo)阻滯，可至猝死、暈厥InfectiveendocarditisEmbolismHeartfailure：發(fā)生左心衰后，病情迅速惡化Gastrointestinalhemorrhage(胃腸道出血)：15-20%胃腸道血管發(fā)育不良心臟瓣膜病19Prognosis一旦出現(xiàn)癥狀，平均壽命僅三年。死亡原因為：左心衰、猝死人工瓣膜置換術(shù)后，遠期存活率優(yōu)于內(nèi)科治療心臟瓣膜病19MedicinetherapyPrincipalobjective：確定狹窄發(fā)生度、觀察病情進展，爭取手術(shù)機會擇期手術(shù)Methods預(yù)防感染性心內(nèi)膜炎、風濕熱AS不能耐受房顫，一旦出現(xiàn)即時轉(zhuǎn)復(fù)處理心衰心臟瓣膜病19PBAP:Percutaneousballoonaorticvalvuloplasty(經(jīng)皮球囊主動脈瓣成形術(shù))適用于高齡患者、不宜換瓣及妊娠等情況，作為姑息治療心臟瓣膜病19Aorticincompetence主動脈瓣關(guān)閉不全心臟瓣膜病19Etiologyandpathology一、ChronicAI（一）：AorticvalvediseaseRheumaticheartdisease:占2/3，由于瓣葉纖維化、增厚縮短，影響閉合，常合并AS及二尖瓣損害Infectiveendocarditis:為單純AI的常見病因Congenitalmalformation:先天性二葉瓣、室間隔缺損伴一葉瓣脫垂、先天性主動脈瓣穿孔Aorticvalvemucinousdegeneration(主動脈瓣粘液樣變性):可致主動脈瓣脫垂心臟瓣膜病19Etiologyandpathology（二）：Aortarootdilatation：瓣環(huán)擴大，瓣葉關(guān)閉不全Syphiliticaortitis(梅毒性主動脈炎)：主動脈炎致主動脈根部擴張,30%呈AIMarfar’ssyndrome：為遺傳性結(jié)締組織病，升主動脈呈梭形擴張，常伴二尖瓣脫垂SeverehypertensionoratherosclerosisIdiopathicdilatationofascendingaorta(特發(fā)性升主動脈擴張)心臟瓣膜病19Etiologyandpathology二、AcuteAIInfectiveendocarditisTraumaDissectionofaorta(主動脈夾層分離):夾層血腫使主動脈瓣環(huán)擴大，或瓣葉、瓣環(huán)被夾層血腫撕裂，多見于馬凡氏綜合征、高血壓或妊娠

Ruptureofprostheticvalve(人工瓣膜破裂)心臟瓣膜病19PathophysiologyChronicaorticregurgitation→LVEDV↑→SBPofLA↑↓aftermanyyears↓DBPofaorta↓→angina

LVEDP↑↓↓Pulsepressure↑

LVdilatingandhypertrophy↓↓Peripheralvascularsign

LAP、PVP↑

↓

Leftheartfailure

心臟瓣膜病19Re