valvular heart disease
DESCRIPTION
Valvular Heart Disease. Dr. Hu Gangying Department of Cardiology Renmin Hospital of Wuhan University. 目的要求. 掌握 常见瓣膜病变病理解剖 病理生理、临床表现、诊断方法 熟悉 心脏瓣膜病治疗原则. Definition. VHD. 心脏瓣膜病是由于炎症、粘液样变性、退行性改变、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(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。. General Consideration. - PowerPoint PPT PresentationTRANSCRIPT
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Valvular Heart Disease
Dr. Hu Gangying
Department of CardiologyRenmin Hospital of Wuhan University
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目的要求掌握
常见瓣膜病变病理解剖病理生理、临床表现、诊断方法
熟悉心脏瓣膜病治疗原则
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DefinitionVHD
心脏瓣膜病是由于炎症、粘液样变性、退行性改变、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(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。
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General Consideration
以下因素Inflammation
Degenerationdeformation畸形 necrosis坏死Trauma
以下瓣膜结构改变Leaflet
valve ring papillary muscle
乳头肌
瓣膜狭窄
瓣膜关闭不全&
Ischemic
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Brief introduction
Bicuspid valve which was followed by aortic valve was viewed as the most susceptive one to rheumatic fever
最常受累为二尖瓣,其次为主动脉瓣
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心脏瓣膜病病因风湿性心脏病 ( 风心病、 rheumatic heart disease)
风湿性炎症过程所致的瓣膜损害主要累及 40岁以下人群我国常见的心脏病之一
瓣膜粘液样变性和老年人瓣膜钙化日益↑VHD comprises a variety of etiologies involving but most cases of it were at one time due to rheumatic heart disease
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Normal MS
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Normal MS
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Mitral Valve Disease
Mitral stenosis
Mitral incompetence
Classification
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Part I
Mitral stenosis
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Mitral StenosisNatural History
Progressive, life long disease
Usually slow & stable in the early years
Progressive acceleration in the later years
呈进展性病程,往往伴随终生
早期进展较缓慢且稳定
晚期病情加速恶化
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Mitral StenosisNatural History
several years latency fever to symptom onset
Additional 10 years before disabling symptoms
感染潜伏多年后出现症状
出现症状后 10 年内可丧失生活能力
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Mitral Stenosis: Etiology & pathology
Most adult patients: MS is the result of rheumatic fever
2/3 of patients with MS are female and 1/2of all without history of rheumatic fever
多数成年患者:二狭由风湿热引起
2/3 是女性, 1/2 无风湿热病史
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Mitral Stenosis: Etiology & pathology
Pathological change is inflammation and thickening of leaflet tips that restricts the motion of the tips
Chronic MS LAE & calcification , LA embolization especially accompanied with AF
病理改变:炎症及瓣叶增厚粘连限制瓣膜活动
慢性二狭 左房增大及钙化,房颤时血栓形成
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Mitral Stenosis: Pathophysiology
(<1cm2)
(1-1.5cm2)
Mild
StenosisAlmost
asymptomatic
Left atrial pressure
Normal valve area: 4-6 cm2(>1.5cm2
)
Moderate Stenosis
Severe Stenosis
severe pulmonary venous congestion
maintain normal flow across the valve
maintain normal cardiac output
shorten diastole
increase mitral flow
rate
&
Right heart
failure
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Pathophysiological progression of mitral stenosis
RV enlargement
pulmonary venous pressure
pulmonary venous congestion
LA pressure elevation
MS
LAE
pulmonary capillary pressure elevation
Slowing LV fulfillment
pulmonary arterial pressure elevation
Right heart failure
二尖瓣狭窄左室充盈减慢
左房压力增高左房增大
肺静脉淤血肺毛细血管压力增高
肺静脉压力增高肺动脉压力增高
右室增大右心衰
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Normal MS
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Normal MS
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Normal MS
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• Manifested after moderate stenosis• 中度狭窄方出现症状 • Often precipitated by AF or pregnancy• 房颤或妊娠时症状加重• Shortness of breath on exertion might
be the first symptom
• 劳累后呼吸困难通常为首发症状
Clinical manifestation: Symptoms
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Clinical manifestation: Symptoms
(Area of mitrial valve < 1.5 ㎝ 2)
• dyspnea -exertion -resting -orthopnea
-paroxysmal nocturnal dyspnea
(瓣口面积< 1.5 ㎝ 2) 呼吸困难 最常见早期症状 劳力性静息时、端坐呼吸、阵发性夜间呼吸困难
肺水肿
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• Hemoptysis– Massive hemoptysis– Suptum with blood,
often with PND or cough
– Pink,frothy suptum– Pulmonary embolism
with hemoptysis• Cough• Hoarseness
Clinical manifestation: Symptoms
• 咯血– 咯大量鲜血– 痰中带血(夜间阵发性呼吸困难)– 粉红色泡沫痰– 肺栓塞伴咯血
• 咳嗽• 声嘶
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Clinical manifestation: Signs
•Mitral facies in severe MS
重度 MS 常有 “ 二尖瓣面容 ” 双颧绀红
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• S1 is accentuated S1 亢进• OS after aortic valve closure 主动脉关闭后开瓣音• Low pitch diastolic murmurs at the apex 心尖区低调舒张期杂音
– 隆隆样或滚筒样,舒张中晚期,递减 - 递增型,伴舒张期震颤• In severe MS with low flow- S1, OS & rumble may be inaudible 重度
二狭时 S1 减弱、开瓣音消失
S1 S2 OS S1
Clinical manifestation: Signs•Sign of MS
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• Pulmonary hypertension & RVE– Dispersion of beat
at apex– RV lift– P2 loudness and
split– Graham Steell
murmur– relative TI with RVE
Clinical manifestation: Signs
• 肺动脉高压及右室 扩大– 心尖搏动弥散– 右室抬举感– P2 亢进及分裂– Graham Steell 杂
音 : 相对性肺闭,舒张期 杂音– 相对性三闭伴右室大
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Mitral Stenosis: Laboratory Examination
X-ray•左房大•右室增大•主动脉结小•肺动脉段突
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Mitral Stenosis: Laboratory Examination
• “二尖瓣型 P 波” ,P 波宽度 >0.12S
• PV1 终末负性向量增大• QRS 波群示电轴右偏和 RVH
ECG
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Mitral Stenosis: Laboratory Examination
Echo-Doppler confirm diagnosis & estimate severity
M-mode echocardiography
Echocardiography
Doppler echocardiography
超声可以确诊及评估严重程度
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The orifice of the stenotic MV can be visualized and. measured mitral valve area is approximately 1.1 cm2
可见狭窄的瓣膜孔,经测定为 1.1 cm2
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Colorful ejection flow at mitral vavle during diastole
Mural thrombosis in LA
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Mitral Stenosis: Laboratory Examination
Catheterization provides assessment of Catheterization provides assessment of regurgitation, LV function and PAP for regurgitation, LV function and PAP for determining whether valvotomy is indicateddetermining whether valvotomy is indicated
Cardiac Catheterization
导管用于术前评估左室功能及肺动脉压
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Mitral Stenosis: Laboratory Examination
It is recommended for the patients who It is recommended for the patients who have a discrepancy between clinical have a discrepancy between clinical and echocardiographic findingsand echocardiographic findings
Cardiac Catheterization
用于临床表现与超声结果不符时
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MS: Diagnosis • Low pitch DM at the apex • 心尖区低调舒张期杂音• X-ray, ECG : LAE• 胸片、心电图示左房大• UCG: final diagnosis • 超声:确诊• DM might be lowered or disappeared if AF• 房颤时舒张期杂音减弱甚至消失
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Differential diagnosis Low pitch DM at the apex• Blood flow through MV increase:
severe MI 、 massive left to right congenital heart disease (eg. VSD 、PDA) 、 hyperkinesis circulation (hyperthyroidism and anemia)
• Austin-Flint murmur : caused by severe AI
• mucous tumor in LA :
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Mitral Stenosis: Complications
• Atrial fibrillation• Acute pulmonary edema• Systemic embolization • Right heart failure • Endocarditis • Pulmonary infections
• 房颤 : 早期• 急性肺水肿 : 严重 MS• 血栓栓塞• 右心衰竭 : 晚期 • 感染性心内膜炎 : 少见• 肺部感染 : 常见
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Mitral Stenosis: Therapy
• General treatment Avoiding from factors cause cardiac overload as follow :
Infection 、 anemia 、 salty diet 、 exhausting• Medical
– Treat rheumatic activity – Diuretics 利尿剂– Endocarditis prophylaxis 预防感染性心内膜炎
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Mitral Stenosis: Therapy• 并发症的处理 1 大量咯血:镇静、利尿 2 急性肺水肿:处理原则同急性左心衰
– 避免使用扩动脉药,选用硝酸酯类药– 正性肌力药对 MS 的肺水肿无益3 房颤4 预防栓塞5 右心衰竭:限钠、利尿
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Mitral Stenosis:Therapy
• Balloon valvuloplasty 球囊扩张术 – Effective long term improvement– 能长期改善症状
• Surgical– Mitral commissurotomy 瓣膜分离术– Mitral Valve Replacement 瓣膜置换术
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Mitral Stenosis: Prognosis
• Asympotomic: 84%• Mild sympotom: 42%• Moderate & severe
sympotom: 15%
• Heart failure: 62%• Embolism: 22%• Infectious
endocarditis : 8%
Average duration from occurrence of symptoms to entire disable 7.3 Years
10 years survival rate Reason for death
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Part IIMitral
Incompetence
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Mitral incompetenceEtiology & pathology
• Valvular-leaflets– Rheumatic– Myxomatous MV– IE– HCM– Congenital
• Annulus– LVE or left heart
failure– Degenerative– Calcification
• 瓣叶– 风湿– 粘液样变– 心内膜炎– 肥厚型心肌病– 先天性
• 瓣环– 左室增大或伴左心衰– 退行性变– 钙化
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• Chordae– Congenital– Acquaired
• Papillary Muscles– Ichemia– Necrosis
• Trauma
• 腱索– 先天性–获得性乳头肌– 缺血– 坏死
• 外伤
Mitral incompetenceEtiology & pathology
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Mitral Incompetence: Pathophysiology
Sorting by rapidity
Text
Text
TextAcute Mitral
IncompetenceChronic Mitral Incompetence
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AABack flow from LV & PV rush into LA
BBLA & LV volume overload
CCPulmonary congestion, edema
DDPulmonary hypertension, RHF
Acute
pressure
D
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Chronic left heart failure
Backflow LAE
Pulmonary hypertensio
n
Right heart
failure
Pulmonary congestion
Chronic LV volume overload
Compensatory LVDEV
Decompensation(increased LV wall tension)
Chronic
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慢性容量负荷代偿 LV 舒张末期容量
代偿性离心性肥大LV收缩期部分血排入 LA代偿期 CO ,超正常
扩大 LA 、 LV适应容量负荷
舒张末压不致明显
不出现肺淤血
持久负荷,引起左心衰, CO
左房压和左心室舒张末压 PA 高压、右心衰竭
Chronic Mitral incompetence: Pathophysiology
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Mitral incompetenceClinical manifestation
Systemic embolization
Hemoptysis
Pulmonary hypertension
Fatigue
Dyspnea & OrthopneaClinical manifestation also present different feature with various rate of progression
It is Similar to MS
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Mitral incompetenceClinical manifestation
急性–轻度仅轻微劳力性呼吸困难–严重很快发生急性左心衰竭,休克
慢性–轻度可终身无症状–严重 CO ,疲乏,肺淤血症状出现晚– 风心病:无症状期长,症状明显损害不可逆– 二尖瓣脱垂:多无症状,晚期出现左心衰竭
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体 征(慢性)心尖搏动:高动力型, LV 时向左下 移位心音:
风心病 S1 ,二尖瓣脱垂和冠心病时多正常A2提前,且分裂增宽严重反流时心尖区可闻 S3二尖瓣脱垂时可有收缩中期喀喇音
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体 征(慢性)心脏杂音:
瓣叶挛缩:全收缩期吹风样杂音,心尖区最响 前叶异常:向左腋下和左肩胛下区传导 后叶异常:胸骨左缘和心底部传导
典型二尖瓣脱垂:随喀喇音之后收缩晚期杂音乳头肌功能失常:收缩早、中、晚期或全收缩期杂音腱索断裂:杂音似海鸥鸣或音乐性反流严重:心尖区紧随 S3 后短促舒张期隆隆样杂音
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Acute mitral incompetence: Signs
Loud P2
S4
Diastolic rumble murmur
S3 present
Systolic murmur may not be pan-systolic
LV may be hyperdynamic
Left Ventricle size normal
心尖搏动为高动力型S2 肺动脉瓣成分亢进心尖区 S4 常见非全收缩期杂音,低调, 呈递减严重反流心尖区 S3 和短促舒张期隆隆
样杂音
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Mitral incompetence Laboratory Examination
Acute mitral incompetence:
– Severe pulmonary congestion, oedema
Chronic mitral incompetence:
LV, LA pulmonary vascularity– Mitral annulus
calcification
X-ray•急性者
– 心影正常或 LA轻度伴明显肺淤血,肺水肿
• 慢性重度反流– LA 、 LV :肺淤血和间质性肺水肿
– 二尖瓣环钙化为致密而粗C 形阴影
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Chronic mitral incompetence
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ECGAcute mitral incompetenceUsually normal EKG,sinus tachycardia presentChronic mitral incompetence
– LA enlargement– Atrial fibrillation– LVH (50% pts. With severe MR)– RVH (15%)– Combined hypertrophy (5%)
ECG features 心电图急性
心电图可正常,窦性心动过速常见慢性重度
LA , LV肥厚和非特异性 ST-T改变RV肥厚征,心房颤动常见
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Mitral Incompetence Laboratory Examination
Function
Add Your Text
Identify etiology & severity of MR
Add Your Text
Evaluation post mitral valve
replacement
Add Your Text
Establish cardiac status after change in
symptoms
Echocardiography
Assess LV function & dimensions
Annual surveillance of
LV function
Estimated EF & LVESD in
asymptomatic severe MR
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Echocardiography
Severe mitral regurgitation due to a dilated annulus and abnormal mitral valve
flail 连枷 posterior mitral valve leaflet
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彩色多普勒 测量返流束面积与左房面积
轻 中 重返流束面积 <
4cm24-8cm2 > 8cm2
返流束面积 / 左房面积 <20%
局限于二尖瓣
20-40%
左房腔中部
> 40%心房顶部
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Mitral Incompetence Laboratory Examination
Cardiac Catheterization
“Golden Standard” for estimating severity of MI
Case I Case II
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Mitral Incompetence :Diagnosis
• Dyspnea• Apex region systolic
murmur• Chest X ray display
heart may\may not to be normal but significant pulmonary congestion
• Notable etiological finding– ( Mitral valve prolapse,
infectious endocarditis, acute myocardial infarction)
Acute突发呼吸困难,心尖区收缩期杂音, X 线心影不大 ,肺淤血明显和有病因可寻,如二脱、 IE 、 AMI 、瓣膜置换术后,诊断不难
急性者
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Mitral Incompetence :Diagnosis
心尖区有典型杂音伴左心房室增大,诊断可成立
确诊有赖超声心动图
– Systolic murmur( apex region )
– LA & LV enlargement
– Diagnosis depends on UCG
Chronic 慢性者
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鉴别诊断三尖瓣关闭不全室间隔缺损胸骨左缘收缩期喷射性杂音
左或右心室流出道梗阻主动脉瓣狭窄肺动脉瓣狭窄肥厚型梗阻型心肌病健康人的无害性杂音以上情况有赖心超确诊
Mitral Incompetence : Differential Diagnosis
Tricuspid insufficiencyinterventricular septal defectsystolic ejection murmurs on left sternal border
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Mitral Incompetence : Complications
A
BC
D
E
Complications
Atrial fibrillation
Systemic Embolizatio
n
Congestive heart failure
Endocarditis
Mitral valve prolapserelated
Complications
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Mitral Incompetence : Management
Acute
To lower pulmonary vein pressure, increase CO and surgical treatment
急性 MI降低肺 V 压,增加 CO (硝普纳、利尿剂)和纠正病因
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Diuretics
VasodilatorsPositive Inotropic Agents
Neuro-hormonal Cytokine Inhibitors
General therapy for cardiac dysfunction
Chronic MI
慢性 MI内科治疗预防 SBE;风心病需抗风湿并预防风湿热无症状、心功能正常者无需特殊治疗,但应随访AF处理同MS ,仅控制室率心力衰竭外科治疗
Mitral Incompetence : Management
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Mitral Incompetence : Management
Mitral Valve Surgery
Only effective
treatment is valve
repair/replacement
Reduces morbidity
and mortality
from severe MI
Operation Should be performed
before onset of severe
symptoms
外科治疗 根本措施,发生不可逆 LV 功能不全之前二尖瓣修补术人工瓣膜置换术
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Prognosis 预后急性:严重返流伴血流动力学不稳,不 及时手术干预,死亡率极高慢性:
慢性重度 MI确诊后内科治疗 5 年存 活率 80% , 10 年存活率 60% 单纯二脱无明显反流,预后良好 年龄> 50岁、明显杂音、反流、房 室增大、瓣叶长而厚,预后差
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Part IIIAortic Stenosis
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Aortic Stenosis Etiology & pathology
• Congenital abnormality is common• 先天性畸形为最常见原因• RHD and degeneration with calcification• 风心病、退行性变、钙化其次
Normal aortic valve
“Normal” geriatric
calcific valve
Congenital bicuspid valve abnormality
Rheumatic Aortic
Stenosis
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病因和病理风心病:多伴关闭不全,二尖瓣损害先天性畸形
先天性二叶瓣畸形:瓣膜钙化及瓣口狭窄其他先天性主动脉瓣畸形:单、三叶瓣少见
退行性老年钙化性主动脉瓣狭窄其他少见原因 : 大的赘生物阻塞瓣口
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Aortic Stenosis: Pathophysiology
Normal aortic valve area ≥3.0cm2
Mild stenosis 1.5-2.5 cm2
Moderate stenosis 1.0-1.5 cm2
Severe stenosis < 1.0 cm2
• 成人瓣口变化– 主动脉瓣口≥ 3.0cm2
– 当瓣口面积减少一半时,收缩期仍无明显跨瓣压差– 瓣口≤ 1.0cm2 时, LV收缩压明显,跨瓣压差显著
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病理生理
LV舒张末容量直至失代偿病程晚期才 室壁应力 、心肌缺血和纤维化等致 CHF
压力负荷 LV室壁向心性肥厚LV顺应性, LV舒张末压 , LA后负荷 , LA代偿性肥厚
肥厚 LA舒张末期有力收缩肺 V 和肺毛细血管免于持续的血管内压力
有利于僵硬 LV充盈维持 CO
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主动脉瓣狭窄引起心肌缺血机制氧耗增加: LV壁增厚、心室收缩压
和射血时间延长LV肥厚,心肌毛细血管密度相对舒张期心腔内压力,压迫心内膜下 冠状动脉LV 舒张末压致舒张期 AO-LV差,冠状动脉灌注
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Clinical manifestation: Symptoms
Exertional dyspnea
Angina pectoris
Syncope & presyncope
sudden death
劳力性呼吸困难晕厥与晕厥前兆
心绞痛
猝死
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主动脉瓣狭窄引起心肌缺血机制晕厥机制
休息时晕厥由于心律失常致 CO
运动周围血管扩张
狭窄瓣口限制 CO 相应
缺血加重使 LV 功能, CO
LV收缩压急剧,过度激活心室内压力感受器,迷走神经传入纤维兴奋血管减压反应,外周血阻力
运动后即刻发生为突然体循环静脉回流 ,影响心室充盈, CO
以上引起体循环动脉压→脑循环灌注压→脑缺血
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Clinical manifestation: signs
• Presence of thrill • “Diamond” shaped, harsh, systolic crescendo-decrescendo • Decreased, delay & prolongation of pulse amplitude• Paradoxical S2 • S4 (with left ventricular hypertrophy)• S3 (with left ventricular failure)
S1 S2 S1 S2
Mild-Moderate Severe
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体 征( 1 )心音
S1正常,严重狭窄呈 S2逆分裂,可闻 S4先天性或瓣叶活动度佳者,胸骨右、左缘和心尖区听到收缩早期喷射音。不随呼吸改变
收缩期喷射性杂音喷射性、粗糙、递增 - 递减型R2 或 L3肋间最响,向颈动脉传导常伴震颤,狭窄越重,杂音越长LV 衰竭或 CO 减少,杂音消失或减弱强度随每搏间的心搏量不同而改变
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体 征( 2 )其他
动脉脉搏上升缓慢、细小而持续(细迟脉)晚期,收缩压和脉压
轻度 AS 并 AI 及动脉床顺应性差老年患者,收缩压和脉压正常甚至升高
严重 AS 者触诊颈动脉搏动明显延迟于心尖部心尖搏动持续有力;如 LV 扩大,可向左下移位
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Aortic Stenosis: Laboratory Examination
X-rayThe LV border
is round & prominent as a result of LVH
Aortic regurgitation in a patient with Marfan syndrome
Marked enlargement of the ascending
aorta with regurgitant flow
marked dilation of the
ascending aorta
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X 线检查心影正常或 LV , LA 可能轻度
主动脉根部常见狭窄后扩张主动脉瓣钙化,肺淤血征象
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Aortic Stenosis: Laboratory ExaminationECG
Marked LVH pattern 、 ST depression 、 T wave inversion
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心电图重度狭窄
LV肥厚伴 ST-T继发性改变LA 大, AVB 、室内传导阻滞心房颤动或室性心律失常
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Aortic Stenosis: Laboratory Examination
• Etiology• Valve gradient and area• LVH• Systolic LV function• Diastolic LV function• LA size• Concomitant regional
wall motion abnormalities
• Coarctation associated with bicuspid AV
Echocardiography
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超声心动图明确诊断和判定狭窄程度重要方法提供心腔大小等多种信息
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诊 断典型 AS 杂音易诊断,确诊有赖UCG
如合并关闭不全和二尖瓣损害多为 风心病单纯主动脉狭窄
年龄< 15Y,单叶瓣畸形多见1665Y,先天性二叶瓣钙化可能性大> 65Y,退行性老年钙化性病变多见
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鉴别诊断二闭、三闭、 ASD 的全收缩期杂音胸骨左缘的其他收缩期喷射性杂音鉴别AS 与其他LV流出道梗阻疾病
先天性主动脉瓣上狭窄:杂音在右侧先天性主动脉瓣下狭窄:无喷射音梗阻性肥厚型心肌病:不向颈部传导
超声心动图
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Aortic Stenosis: Complication
• Arrhythmia• SCD• IE• Systemic
embolization• HF• GIB
• 心律失常• 心源性猝死• 感染性心内膜炎• 体循环栓塞• 心衰• 消化道出血
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Aortic Stenosis: Management
General Therapy
Medical Treatment Operation Balloon Aortic
Valvuloplasty
Life style controlling & reporting development of any symptoms possibly related to AS for asymptomatic
Stabilize patients (symptomatic or have indications) for subsequent surgery
Replacement of the aortic valve results in substantial clinical and hemodynamic improvement
Especially for children, adolescents, and young adults with congenital noncalcific AS
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内科治疗目的:确定狭窄程度,观察狭窄进展情况措施:
预防 SBE ,风湿热定期复查:无症状轻度 2 Y,中重度 6 ~ 12月频发房早予抗心律失常药物,预防 AF心绞痛可试用硝酸酯类药物控制心力衰竭不可使用作用于小动脉血管扩张剂,以防血压过低
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外科治疗 人工瓣膜置换术为治疗成人AS 的主要方法
无症状的轻、中度狭窄患者无手术指征重度狭窄伴心绞痛、晕厥或心衰症状为主要指征无症状重度狭窄患如伴有进行性心脏增大和明显CHF ,应手术
严重 CHF 、高龄、合并AI 或 CAD ,增加手术和术后晚期死亡风险,但不是手术禁忌证
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经皮球囊主动脉瓣成形术适应证
严重 AS 的心源性休克严重 AS急诊非心脏手术治疗因有 CHF而具极高手术危险,作为以后换瓣过渡
严重 AS 的妊娠妇女严重 AS ,拒绝手术者
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预 后可多年无症状一旦出现症状,病情恶化症状后平均寿命 3 年死亡原因:心衰 70% 、卒死
15%
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Part VIAortic
Incompetence
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病因与病理•主动脉瓣和(或)主动脉根 部疾病所致
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急 性感染性心内膜炎创伤主动脉夹层人工瓣膜撕裂
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慢 性主动脉瓣疾病
风心病 : ( 2/3 )常合并二尖瓣损害感染性心内膜炎:常见原因先天性畸形:二叶瓣、 VSD主动脉瓣粘液样变性:脱垂强直性脊柱炎:瓣叶基底部和远端边缘增厚
主动脉根部扩张梅毒性主动脉炎、 Marfan综合征强直性脊柱炎、特发性升主动脉扩张严重高血压和(或)动脉粥样硬化
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病理生理:急性舒张早期 LV 压很快,超过 LA 压,二尖瓣 在舒期提前关闭,防止 LA 压过度、肺水肿
舒张期血流 AO反流 LV+LV接纳 LA 充盈血流LV 容量负荷急剧 LV 舒张压急剧
肺淤血肺水肿
急性者 LV 舒张末容量仅能有限,即使LV 功能正常或,代偿性心动过速, CO仍
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病理生理:慢性 有利代偿:长期维持正常 CO 和肺 V 压无明显
LV 对慢性容量负荷过度反应为 LV 舒张末容量,总 CO
LV 扩张,不至于因容量负荷过度而明显 LV 舒张末压离心性肥厚使 LV 厚度 / 心腔半径不变,室壁应力正常运动时外周阻力和心率伴舒张期缩短,反流减轻。
失代偿晚期收缩功能降低,左心衰竭发生LV 重量,心肌氧耗
AO 舒张压,冠状动脉血流心肌缺血LV 功能恶化
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症 状急性:轻者可无症,重者出现急性左心 衰和低血压慢性:可多年无症状
最先的主诉为与心搏量增多有关, 心悸、心前区不适 晚期始出现左心衰竭表现 心绞痛较主动脉瓣狭窄少见 常有体位性头昏,晕厥少见
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血压和脉压正常或舒张压稍低,脉压稍增大无明显周围血管征。心尖搏动正常心动过速常见S1 减低或消失 ,S2 肺 A 瓣成分增强 ,S3 常见杂音较慢性者短而调低出现 Austin-Flint 杂音,多为舒张中期杂音
AI Clinical Manifestation Signs : Acute
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Chronic AI Clinical Manifestation: Peripheral Signs
实验试剂600 元
Peripheral Signs
Duroziez’s sign
femoral retrograde
bruits
Traube’s sign
pistol shot femorals
De Musset’s sign
systolic head
bobbing
周围血管征常见:点头征、枪击音、双期杂音
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Chronic AI Clinical Manifestation: Signs
• Apex– Enlarged– Displaced– Hyper-dynamic– Palpable S3 – Austin-Flint murmur
• Aortic diastolic murmur– length correlates with severity
(chronic AR)– in acute AR murmur shortens as
Aortic DP=LVEDP– in acute AR - mitral ahead closure
心尖搏动 向左下移位,常弥散而有力心音
S1减弱, S2主动脉瓣成分减弱或缺如S2多为单一音,心底部可闻及收缩期喷射音
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Clinical Manifestation : Signs
S1 S2 S1
• Widened pulse pressure • High pitched, blowing,
decrescendo DM at left sternal border
• Best heard at end-expiration & leaning forward
• Hands & Knee position
Murmurs
• 脉压大 • 胸骨左缘高调、叹气样、
递减的舒张期杂音 • 呼气末期及前倾时明显 • Austin-Flint 杂音
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Aortic Incompetence : Laboratory ExaminationX-ray
The LV border is round &
prominent as a result of LVH
Aortic regurgitation in a patient with Marfan syndrome
Marked enlargement of the ascending
aorta with regurgitant flow
marked dilation of the
ascending aorta
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Aortic IncompetenceLaboratory Examination
X-ray
Aortic incompetence with massive diffuse aortic dilation (companied with Left atrial & ventricular enlargement)
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Aortic IncompetenceLaboratory Examination
Left ventricular hypertrophy with prominent positive anterior T waves has been described with “diastolic overload” syndrome
ECG
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Aortic IncompetenceLaboratory Examination
Echo have decisive effort in diagnosis of AI
Echocardiography
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Aortic Incompetence Diagnosis & Differential Diagnosis
S1↓A2 ↓Cardiac base region SMAustin-Flint murmursPrecordial Palpable S3 SBP↑ , DBP↓ , pulse pressure↑Dilatation of aortaLA & LV enlargement
Diagnosis
典型舒张期杂音伴周围血管征,可诊断, UCG确诊
慢性如合并主动脉瓣或二尖瓣狭窄,支持风心病诊断
诊 断
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鉴别诊断杂音于胸骨左缘明显时 应与 Graham Steell 杂音鉴别严重肺 A 高压伴肺 A 扩张所
致肺A 瓣关闭不全常有肺动脉高压体征
Graham Steell Graham Steell MurmurMurmur
Pulmonary incompetence results
from Severe pulmonary artery
hypertension
Differential Diagnosis
Aortic Incompetence :Differential Diagnosis
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并发症感染性心内膜炎较常见室性心律失常常见心脏性猝死少见心力衰竭在急性者出现早慢性者于晚期始出现
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Aortic Incompetence : Management
Acute Stabilize patients for subsequent surgery
Chronic
Medication Beta-blocking agents Vasodilator
ACEIFor
Retarding progression
Operation Surgery is fundamental therapy for AISurgery may be done as soon as possible
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急 性外科治疗为根本措施,内科治疗仅为术前准备目的:降低肺 V 压,增加 CO ,稳定血流动力学
血流动力学不稳定者,立即手术动脉夹层即使伴轻或中度反流,紧急手术活动性 SBE ,争取 710 天强有力抗生素治疗后手术创伤性或人工瓣膜障碍,紧急或择期手术药物可控制,心功能代偿好,手术可延缓真菌性 SBE所致,无论反流轻重,需早日手术
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慢 性 内科治疗
预防 SBE.风湿热梅毒性主动脉炎应予一疗程青霉素治疗舒张压> 90mmHg应用降压药无症状的轻或中度反流者,限制重体力活动CHF应用血管扩张药、利尿剂和洋地黄类药物心绞痛可试用硝酸酯类药物积极纠正房颤和缓慢性心律失常如有感染应及早积极控制
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慢 性外科治疗(人工瓣膜置换术):主要
方法不可逆 LV 功能不全发生之前进行,
不宜过晚无症状和 LV 功能正常的严重反流不需手术,随访
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预 后急性重度如不及时手术,易死于左心衰慢性者无症状期长重度者确诊后 5 年存活率 75% 10 年存活率 50%症状出现后,病情迅速恶化 心绞痛者 5 年内死亡 50% 严重左心衰者 2 年内死亡 50%
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Part VTricuspid & pulmonic
Valve Disease
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Tricuspid Stenosis,TS Etiology , Pathology & PathophysiologyEtiology Rheumatic is origin
Changes of TS resemble those of MS Pathology
Pathophysiology
Transvalvular blood flow RA pressure
Systemic venous pressure
RV output
风湿为主要病因
病理改变与二狭类似
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Clinical ManifestationSymptoms & Signs
• Fatigue• Systemic congestion • AF• Pulmonary
Embolization
Symptoms
•疲惫•体循环淤血•肺栓塞•房颤
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• Tall jugular venous a wave pulse
• hepatic pulsation• Ascites• Opening snap
Signs
Clinical ManifestationSymptoms & Signs
• 颈静脉扩张• 开瓣音• 舒张期杂音• 可触及肝搏动• 腹水和全身水肿
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Tricuspid Stenosis Laboratory Examination
II & V1 leads P wave >0.25mv, indicate RAE
Cardiomegaly with obvious
RAE
changes of TS resemble those
in MS
ECGX-ray
ECHO
II & V1 导联 P 波 >0.25mv, 提示右房大
心影增大 右房明显超声改变与二狭类似
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A CB
• Sodium restriction
• Diuretic therapy
Fundamental approach to management of severe TS
For children & young
adult with anomaly
Medical Treatment
Tricuspid valve
replacement
Tricuspid Stenosis :Management
Tricuspid balloon
valvuloplasty
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Tricuspid Incompetence, TI Etiology , Pathology & Pathophysiology
Dilatation of the RV and of the tricuspid annulus causing functional TI
A variety of disease can affect the tricuspid valve directly and lead to primary TI
• Ebstein anomaly• Rheumatic heart disease
RV volume overload
Systemic venous
hypertension
Right heart failure
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Tricuspid IncompetenceClinical Manifestations
• jugular pulsations• 颈静脉搏动• Systolic pulsations of
liver • 肝收缩期搏动• S3 accentuated by
inspiration• 吸气时 S3 增强• DM另外,体循环淤血的体征
SignsSymptoms• Fatigue• Abdominal
distension疲乏、腹胀等右心衰的表现 Complication Fibrillation Pulmonary embolism
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Tricuspid Incompetence Laboratory Examination
• RAE• RBBB• AF
• RAE 、 RVE • Pleural effusion
ECG X-ray
Key to diagnosis of TI
ECHO
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Tricuspid Incompetence Management
Key point for treatmentKey point for treatment
AA TI in the absence of pulmonary hypertension usually is well tolerated
BBSevere TI and primary tricuspid valve disease require Operation
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Pulmonic Stenosis & Incompetence Etiology , Pathology & Pathophysiology
The congenital form is the most common cause of it
PS
changes of PI resemble those of TIPI
RV volume overload
Systemic venous
hypertension
Right heart failure
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Pulmonic Incompetence Clinical Manifestations & Management
• wide splitting of S2 S2 宽分裂• Graham Steell Murmur Graham Steell 杂音• S3 and S4 are augmented by inspiration 吸气时 S3 与 S4 增强
Clinical Manifestations of it are overshadowed by other one
Signs
Management
PI alone is seldom severe enough to require specific treatment
主要治疗肺高压的原发病 MS
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Pulmonic Incompetence Laboratory Examination
• Be helpful to diagnosis of PI
ECG X-ray ECHO
• 肺高压者有右室肥厚征• RVE • Chunk of
pulmonary Artery Dilation
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Part ⅥMultivalvular Heart Disease
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Multivalvular Heart Disease & Etiology
Key pointKey point11
Key pointKey point22
一种疾病同时损害几个瓣膜
一个瓣膜损害致心脏容量或压力负荷过重相继引起近端瓣膜功能受累
Key pointKey point33
不同疾病分别导致不同瓣膜损害
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Multivalvular Heart Disease & Pathophysiology
Key pointKey point11
Key pointKey point22
严重损害掩盖轻的损害
近端损害影响较显著,而掩盖轻的损害
Key pointKey point33
总的血液动力学异常明显
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Multivalvular Heart Disease Sorting by morbidity
22
55
33
44
11心房肌纤维肥大 心肌纤维化
心房结构改变
心房肌细胞退行性变
MS & AI
MS & AS
AS & MI
AI & MIMS & TI /PI
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Examples of common multivalvular heart disease
MS+AI MS 导致心排血量下降,使 LV扩大延缓,周围血管征缺如
BB
严重 MS 常掩盖 AS 的表现
AS+MI为危险的多瓣膜病,相对较少见。 AS 增加左室后负荷使MI返流加重,前向心搏量减少较二者单独存在时明显
MS+AS
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