第08章-心脏瓣膜病课件

Valvular Heart Disease心脏瓣膜病心脏瓣膜病Valvular Heart Disease心脏瓣膜病1心脏瓣膜病心脏瓣膜病 是指心瓣膜及瓣下装置由于炎症、变性、粘连、缺血性坏死、创伤、老化或钙质沉着及先天性发育异常等原因，使单个或多个瓣膜发生急性或慢性的狭窄或关闭不全，导致前向血流障碍和/或返流的一组疾病。临床上最常受累的为二尖瓣，其次为主动脉瓣。风湿性心脏病风湿性心脏病简称风心病，仍是我国主要的心脏病，是风湿性炎症过程所致瓣叶损害。根据人群发病率调查已有下降趋势。心脏瓣膜病 是指心瓣膜及瓣下装置由于炎症、变性、粘连、缺2Mitral valve disease 二尖瓣疾病二尖瓣疾病Mitral valve disease 二尖瓣疾病3Mitral stenosis (MS)二尖瓣狭窄Mitral stenosis (MS)二尖瓣狭窄4Etiology and Pathology（病因和病理）n nRheumatic heart disease(风湿性心脏病)n nCongenital malformation(先天性畸形)n nSenile mitral annulus and subvalvular calcification(老年人二尖瓣环及环下区钙化)Etiology and Pathology（病因和病理）5Pathophysiology(病理生理)n nThe cross-sectional area of the mitral valve orifice(瓣环口面积）uuNormal adults 4-6cmuuMild MS 2cmuuModerate MS 1.5cmuuSevere MS 1.0cmPathophysiology(病理生理)The cross6n nThe effect on LA and cardiac output of MS uuMild MS：LA压力轻度升高，心排血量正常uuSevere MS：跨瓣压差增大(20mmHg)LA压力升高（25mmHg)；休息时心排血量正常或减少n nThe effect on the pulmonary circulation and respiration of elevated left atrium pressureThe effect on LA and cardiac o7LA PVP、PCP lung congestion/pulmonary edema pulmonary artery intima hyperplasia and thickening（肺动脉内膜增生肥厚）PAP（肺动脉压升高）Right heart failure（右心衰竭）LA PVP、PCP lung congesti8Remarks(备注)n nPAP：肺动脉压n nPCP：肺毛细血管压n nPVP肺静脉压Remarks(备注)PAP：肺动脉压9Clinical situation(临床表现)一、Symptom(中度狭窄始出现症状)1.1.Exertion dyspnea(劳力性呼吸困难)2.2.Hemoptysis(咯血)支气管静脉压破裂出血 肺梗死 肺水肿Clinical situation(临床表现)一、Symp103.Hoarseness（声嘶）4.Cough(咳嗽）LA增大压迫左主支气管，支气粘膜淤血水肿，易致感染 扩大的LA、肺A压迫喉返NHoarseness（声嘶）11Clinical situation二、Physical Sign(体征)nMitral facies(Mitral facies(二尖瓣面容二尖瓣面容)nS S1 1，可闻及，可闻及OS(OS(开瓣音开瓣音)nCardiac apex DM(Cardiac apex DM(心尖区舒张期杂音），心尖区舒张期杂音），often accompanying diastolic thrill(often accompanying diastolic thrill(舒张震颤）舒张震颤）nRVRV，P P2 2 excessive(excessive(亢进亢进)，Relative SM of TIRelative SM of TI(相对性三尖瓣关闭不全收缩期杂音相对性三尖瓣关闭不全收缩期杂音)Clinical situation二、Physical 12Laboratory examination(实验室检查)n nXRayuu二尖瓣型心：左房右室大，主动脉结缩小，肺动脉扩张，肺淤血n nECG uuP 0.12s,RV1 1,电轴右偏，心房纤颤，粗f波n n Echocardiogram(超声心动图)：是确诊、定量MS的可靠方法Laboratory examination(实验室检查)13u M型：二尖瓣前后叶同向运动u 二维：狭窄瓣膜形态结构，瓣口面积，房室大小u 连续多普勒：测定血流速度、跨瓣压差Cardiac catheterization(心导管术)u 测定肺毛细血管压和左室压，确定跨瓣压差，明确狭窄程度 M型：二尖瓣前后叶同向运动14Diagnosis and Differential diagnosis(诊断和鉴别)n nDiagnosisuu心尖区DMLA扩大及实验室检查可诊断，超声有确诊价值n nDifferential diagnosisuu二尖瓣口血流增加uuAustin Flint杂音uu左房粘液瘤：随体位改变的DMDiagnosis and Differential dia15Complication（并发症）一、Atrial fibrillation(心房纤颤)uu见于5%以上的患者；房颤使心排量下降20%，常是体力活动明显受限的开始二、Acute pulmonary edema(急性肺水肿)uu为重度MS最严重的并发症及致死原因三、Embolism(栓塞)uu80%有房颤、大左房（D55mm)；2/3为脑栓塞，也可有周围及内脏栓塞Complication（并发症）一、Atrial fibr16Complication（并发症）四、Right heart failure(右心衰竭)五、Pulmonary infection(肺部感染)Complication（并发症）四、Right heart17Prognosis(预后)n n无症状者可存活多年，一旦有症状至致残平均7.4年n n死亡原因多为上述并发症Prognosis(预后)无症状者可存活多年，一旦有症状至致18Therapy(治疗)1.General therapy(一般治疗)：预防风湿热及感染性心内膜炎2.Hemoptysis(咯血)：减低肺静脉压力3.Atrial fibrillation：快速心室率时应用洋地黄4.Right heart failure：以利尿为主Therapy(治疗)General therapy(一般治19Therapy(治疗)4.Acute pulmonary edema：处理同急性左心衰；注意二尖瓣狭窄时用正性肌力药物不好，仅当房颤快速心室率时应用5.Mechanic therapeutics(机械治疗)MS：经皮球囊二尖前瓣成型术；外科手术Therapy(治疗)Acute pulmonary ede20Mitral incompetence:MI二尖瓣关闭不全Mitral incompetence:MI二尖瓣关闭不全21Etiology and Pathology（病因病理）n nDuring 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 MI.Etiology and Pathology（病因病理）D22一、Chronic MI1.Rheumatic heart disease:The leftlets of mitral valve fibrose,thicken,shorten and often accompany MS and aortic valve disease2.Mitral valve prolapse(二尖瓣脱垂)3.CHD：Chronic ischemia(缺 血)or infarction(梗死)lead to fibrosis and functional disorder of papillary muscle一、Chronic MIRheumatic heart di23一、Chronic MI4.Calcification of mitral ring and subvalvular(二尖瓣环及环下区钙化)5.Infective endocsrditis6.Rupture of chordae tendineae(unknown cause)7.LV enlarged significantly(左室显著扩大)8.Else 一、Chronic MI Calcification of 24二、Acute MI1.Rupture of chordae tendineae(腱索断裂)2.Endocarditis leads to the leftlets of valve destruction(心内膜炎致瓣叶毁损)3.Acute myocardial infarction(急性心肌梗死)4.Trauma results in rupture of the mitral valve component(创伤使二尖瓣器破裂)5.Rupture of prosthetic valve(人工瓣膜开裂)二、Acute MIRupture of chordae 25Pathophysiologyn nMI LVEDV LV hypertrophy LVEDP,LALV failure Pulmonary congestion PAP Right heart failurePathophysiologyMI LVEDV LV 26Clinical situation(临床表现)一、Symptomuu轻轻度度MIMI可可终终身身无无症症状状，严严重重MIMI心心排排血血量量减减少，感乏力、呼吸困难少，感乏力、呼吸困难二、Physical SignuuHeaving apex impulse(Heaving apex impulse(抬举性心尖搏动抬举性心尖搏动)uuCardiac Cardiac soundsound：S1S1（重重度度MIMI），S2S2分分裂裂，闻及闻及S3S3uuCardiac Cardiac murmurmurmur：从从S1S1后后立立即即开开始始，与与S2S2同同时时终终止止的的SMSM，可可伴伴收收缩缩期期震震颤颤，向向左左腋腋 、左左肩肩胛胛下下区区传传导导；乳乳头头肌肌功功能能不不全全、腱腱索索断断裂的杂音似海鸥鸣叫样裂的杂音似海鸥鸣叫样Clinical situation(临床表现)一、Symp27Laboratory examinationn nXRayn nECGn nEchocardiogramuu二维超声：可显示二尖瓣的形态结构，提供心室大小，明确病因uu彩超连续多普勒：可用于二尖瓣心房侧探及收缩期射流，半定量返流量Laboratory examinationXRay28Diagnosis and Differential diagnosisn n心心尖尖区区SMSM心心房房、心心室室增增大大，诊诊断断MIMI可可成立，确诊有赖于超声心动图成立，确诊有赖于超声心动图n n应与以下情况相鉴别：1.Tricuspid incompetence（三尖瓣关闭不全）：胸左缘4、5肋间SM，可传至心尖区，杂音吸气时增强，伴颈静脉收缩期搏动，RV2.VSD（室间隔缺损）Diagnosis and Differential dia293.Systolic ejection murmur in left border of sternum 生理性杂音 功能性杂音 主、肺动脉根部扩张 左或右室流出道梗阻Systolic ejection murmur in le30n n Atrial fibrillationn n Infective endocarditis n n Embolism n n Heart failureComplication Atrial fibrillationComplicati31Prognosisn n急性严重返流者，若不及时手术，极难存活n n慢性MI无症状期长，一旦发生左心衰竭，预后不良Prognosis急性严重返流者，若不及时手术，极难存活32Therapyn nMedical therapy(内科治疗)uuPrevent endocarditis and rheumatic feveruuPatients who are asymptomatic and having normal cardiac function neednt therapy but regular follow-up(定期随访).uuComplication are cured in patients with complication.TherapyMedical therapy(内科治疗)33n nSurgical treatmentuu Prosthetic valve replacement为主要手术方法，趋向早期手术为主要手术方法，趋向早期手术有有症症状状者者应应在在LVEFLVEF0.50.5，平平均均肺肺动动脉脉压压 20mmHg20mmHg之前手术之前手术产产生生左左室室功功能能不不全全、LVEF LVEF 0.30.30.50.5、年年龄龄5555岁、岁、LVEDD80mm LVEDD80mm，已不置换瓣，已不置换瓣uu Valvuloplasty Valvuloplasty of of mitral mitral valve valve(二二尖尖瓣瓣整整复复术术)优点：不需长期抗凝，优点：不需长期抗凝，LVLV功能恢复较好功能恢复较好Surgical treatment34Aortic Valve Disease主动脉瓣疾病Aortic Valve Disease主动脉瓣疾病35Aortic stenosis(AS)主动脉瓣狭窄Aortic stenosis(AS)主动脉瓣狭窄36Etiology and Pathology1.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Etiology and PathologyRheumati37Pathophysiologyn nThe cross-sectional area of the aortic valve orifice(瓣环口面积）uuNormal adult 3.0cmuuThe area 1.0cm,LVSP,transvalve pressure gradient manifest(跨瓣压差明显)PathophysiologyThe cross-secti38ASAfter loadingLV hypertrophyLVEDP ASAfter loadingLV hypertrophyLVEDP LA amplificationLA amplification PAP PCPPAP PCP Lung congestion and Lung congestion and edemaedemaMyocardial ischemiaMyocardial ischemia Myocardial contractilityMyocardial contractility Heart failureHeart failureASAfter loadingLV hypertrop39Clinical situationn nSymptomuuAS Triple syndrom(AS三联症)t tDyspnoea(呼吸困难呼吸困难):Lung congestiont tAngina(心绞痛)Causing byCausing by t tSynocope(晕厥)cardiac outputcardiac outputClinical situationSymptom40Clinical situationn nPhysical signPhysical sign1.Cardiac sound:S1 is normal,S2 is paradoxical Cardiac sound:S1 is normal,S2 is paradoxical splitting(splitting(逆分裂逆分裂),S4 may be heard),S4 may be heard2.Cardiac murmur:Cardiac murmur:：SM is heard on the second SM is heard on the second intercostal space(intercostal space(肋间肋间)of right border of)of right border of sternum,and radiate to cervical part(sternum,and radiate to cervical part(颈部颈部),),left inferior border of sternum and cardiac left inferior border of sternum and cardiac apex accompanying thrill apex accompanying thrill 3.Cardiac dilatation(Cardiac dilatation(心脏扩大心脏扩大)，SBP and SBP and pulse pressure decreasepulse pressure decreaseClinical situationPhysical sig41Laboratory examination1.X-Ray：心影可正常或稍大，晚期见肺淤血2.ECG：可有左室肥厚劳累征，及各种心律失常3.Echocardiogram：为确定、定量AS的重要方法4.Cardiac catheterization：可根据左室-主动脉压差计算瓣口面积Laboratory examinationX-Ray：心影42Diagnosis and Differential diagnosisn nDiagnosisuu典型的收缩期杂音，易于诊断；多瓣膜病变提示风心病uu单纯AS：根据年龄，应考虑单叶瓣、二叶瓣膜及老年退行性变，确诊有赖于超声心动图n nDifferential diagnosisuuAS应与左室流出道梗阻性疾病鉴别Diagnosis and Differential dia43Complication1.ArrhythmiaArrhythmia：10%10%可发生房颤、室性心律失常、可发生房颤、室性心律失常、房室传导阻滞，可至猝死、晕厥房室传导阻滞，可至猝死、晕厥2.Infective endocarditisInfective endocarditis3.EmbolismEmbolism4.Heart failureHeart failure：发生左心衰后，病情迅速恶化：发生左心衰后，病情迅速恶化5.Gastrointestinal hemorrhage(Gastrointestinal hemorrhage(胃肠道出血胃肠道出血)：15-20%15-20%胃肠道血管发育不良胃肠道血管发育不良ComplicationArrhythmia：10%可发生房44Prognosisn n一旦出现症状，平均寿命仅三年。uu死亡原因为：左心衰、猝死n n人工瓣膜置换术后，远期存活率优于内科治疗Prognosis一旦出现症状，平均寿命仅三年。45Medicine therapyn nPrincipal objective：确定狭窄发生度、观察病情进展，争取手术机会择期手术n nMethodsuu预防感染性心内膜炎、风湿热uuAS不能耐受房颤，一旦出现即时转复uu处理心衰Medicine therapyPrincipal obje46PBAP:Percutaneous balloon aortic valvuloplasty(经皮球囊主动脉瓣成形术)n n适用于高龄患者、不宜换瓣及妊娠等情况，作为姑息治疗PBAP:Percutaneous balloon ao47Aortic incompetence主动脉瓣关闭不全Aortic incompetence主动脉瓣关闭不全48Etiology and pathology一、一、Chronic AIChronic AI（一）：Aortic valve diseasedisease1.Rheumatic heart disease:Rheumatic heart disease:占占2/32/3，由于瓣叶纤，由于瓣叶纤维化、增厚缩短，影响闭合，常合并维化、增厚缩短，影响闭合，常合并ASAS及及二尖瓣损害二尖瓣损害2.Infective endocarditis:Infective endocarditis:为单纯为单纯AIAI的常见病因的常见病因3.Congenital malformation:Congenital malformation:先天性二叶瓣、室先天性二叶瓣、室间隔缺损伴一叶瓣脱垂、先天性主动脉瓣间隔缺损伴一叶瓣脱垂、先天性主动脉瓣穿孔穿孔4.Aortic valve mucinous degeneration(Aortic valve mucinous degeneration(主动脉主动脉瓣粘液样变性瓣粘液样变性):):可致主动脉瓣脱垂可致主动脉瓣脱垂Etiology and pathology一、Chroni49Etiology and pathology（二）：Aorta root dilatation orta root dilatation：瓣环扩大，瓣叶：瓣环扩大，瓣叶关闭不全关闭不全1.Syphilitic aortitis(Syphilitic aortitis(梅毒性主动脉炎梅毒性主动脉炎)：主动主动脉炎致主动脉根部扩张脉炎致主动脉根部扩张,30%,30%呈呈AIAI2.Marfars syndromeMarfars syndrome：为遗传性结缔组织病，：为遗传性结缔组织病，升主动脉呈梭形扩张，常伴二尖瓣脱垂升主动脉呈梭形扩张，常伴二尖瓣脱垂3.Severe hypertension or atherosclerosisSevere hypertension or atherosclerosis4.Idiopathic dilatation of ascending aorta(Idiopathic dilatation of ascending aorta(特发特发性升主动脉扩张性升主动脉扩张)Etiology and pathology（二）：Aor50Etiology and pathology二、二、Acute AIAcute AI1.Infective endocarditisInfective endocarditis2.TraumaTrauma3.Dissection of aorta(Dissection of aorta(主动脉夹层分离主动脉夹层分离):):夹层血夹层血肿使主动脉瓣环扩大，或瓣叶、瓣环被夹层肿使主动脉瓣环扩大，或瓣叶、瓣环被夹层血肿撕裂，多见于马凡氏综合征、高血压或血肿撕裂，多见于马凡氏综合征、高血压或妊娠妊娠4.Rupture of prosthetic valve(Rupture of prosthetic valve(人工瓣膜破裂人工瓣膜破裂)Etiology and pathology二、Acute 51PathophysiologyChronic aortic regurgitationLVEDVSBP of LVChronic aortic regurgitationLVEDVSBP of LV after many years after many years DBP of aortaanginaDBP of aortaangina LVEDP LVEDP Pulse pressurePulse pressure LV dilating and hypertrophy LV dilating and hypertrophy Peripheral vascular signPeripheral vascular sign LAP LAP、PVPPVP Left heart failure Left heart failurePathophysiologyChronic aortic 52Remarks(备注)n nSBP：收缩压DBP：舒张压n nPVP：肺静脉压LAP：左房压n n LVEDP：左室舒张末压n nPeripheral vascular sign：周围血管征Remarks(备注)SBP：收缩压DBP：舒张压53Clinical situationn nPhysical Sign:SP,DP,PP Physical Sign:SP,DP,PP 1.Peripheral vascular sign1.Peripheral vascular signt tWater-hammer pulse(Water-hammer pulse(水冲脉水冲脉)t tPistol shot sound(Pistol shot sound(枪击音枪击音)t tDe musset signs(De musset signs(点头运动）点头运动）t tDuroziez signs(Duroziez signs(杜氏双重杂音杜氏双重杂音)t tCapillary pulse(Capillary pulse(毛细血管搏动毛细血管搏动)t tCarotid artery pulse(Carotid artery pulse(颈动脉搏动颈动脉搏动)Clinical situationPhysical Sig54Clinical situationn nPhysical SignPhysical Sign2.Apical impluse displaced to left and down(2.Apical impluse displaced to left and down(心心尖搏动向左下移位尖搏动向左下移位)3.Cardiac sound3.Cardiac sound：S1S1、S2S2减弱，可闻及减弱，可闻及S3S34.Cardiac murmur4.Cardiac murmur：舒张早期杂音，吹风性，：舒张早期杂音，吹风性，呼气末期易闻及，于左胸第三肋间明显。重呼气末期易闻及，于左胸第三肋间明显。重度返流者，心尖区可闻及舒张早期隆隆样杂度返流者，心尖区可闻及舒张早期隆隆样杂音（音（Austin FlintAustin Flint杂音）杂音）Clinical situationPhysical Sig55Laboratory examinationn nX-Ray：急性者心脏大小正常；有肺淤血、肺水肿者，心胸比值增大，LV、LA增大，升主动脉扩张及左心衰、肺淤血n nECG：LV肥厚劳损n nEchocardiogramLaboratory examinationX-Ray：急性56Diagnosis and Differential diagnosisn nDiagnosisuu 典型杂音周围血管征n nDifferential diagnosisuu与Graham Stell 杂音的区别：见于严重肺动脉高压及肺动脉扩张的肺动脉瓣关闭不全uuAustin Flint 杂音与MS杂音鉴别Diagnosis and Differential dia57Complicationn nInfective endocarditisn nVentricular arrhythmia(室性心律失常)n nHeart failureComplicationInfective endocard58Therapyn n对于急性AI，外科治疗为根本措施n nMedicine therapy mainly include：1.预防感染性心内膜炎、风湿热2.无症状的轻、中度AI者定期随访，限制体力活动3.心衰时强心、利尿及血管扩张药物、对症治疗Therapy对于急性AI，外科治疗为根本措施59Therapyn nSurgical treatmentSurgical treatment：严重：严重AIAI，需要换瓣治疗，需要换瓣治疗uuIndications for surgery Indications for surgery：t t有症状的左室功能不全者有症状的左室功能不全者t t虽无症状，但已有左室功能不全，左室收虽无症状，但已有左室功能不全，左室收缩末期容积增加，缩末期容积增加，EFEF下降下降uuSurgical contraindiction Surgical contraindiction：LVEF0.15-0.20LVEF0.15-0.20，LVEDD80mmLVEDD80mm，或，或 LVEDVI300ml/m LVEDVI300ml/m TherapySurgical treatment：严重AI60Multivalvular heart disease多瓣膜病Multivalvular heart disease多瓣膜61Etiology n n一种疾病同时损害几个瓣膜n n一瓣损害相继引起近端瓣膜功能受累n n不同疾病分别导致不同瓣膜损害Etiology 一种疾病同时损害几个瓣膜62Pathophysiology 1.严重损害掩盖轻的损害2.近端损害影响较显著，而掩盖轻的损害3.总的血液动力学明显异常Pathophysiology 严重损害掩盖轻的损害63Examples of common multivalvular heart diseasen nMS+AI：MS导致心排血量下降，使LV扩大延缓，周围血管缺如n nMSAS：严重MS常掩盖AS的表现n nASMI：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Examples of common multivalvul64p经常不断地学习,你就什么都知道。你知道得越多,你就越有力量pStudyConstantly,AndYouWillKnowEverything.TheMoreYouKnow,TheMorePowerfulYouWillBe写在最后经常不断地学习,你就什么都知道。你知道得越多,你就越有力量写65谢谢大家荣幸这一路，与你同行ItS An Honor To Walk With You All The Way演讲人：XXXXXX 时 间：XX年XX月XX日 谢谢大家演讲人：XXXXXX 66