内科学教学课件：心脏瓣膜病

Valvular Heart Disease 心脏瓣膜病心脏瓣膜病某章(或某三级学科)教学大纲要求要求要求内容内容学时学时掌握掌握1、二尖瓣和主动脉瓣病变的病因、病理生理、临床表现、诊断与鉴别诊断及防治。2、本病与风湿热的关系、常见并发症、手术治疗指征，介入性治疗指标。50分钟分钟25分钟分钟熟悉熟悉1、2、了解了解1、了解除风湿热以外的其它病因。2、三尖瓣及肺动脉瓣疾病5分钟分钟自学自学注：适当标记重点和难点。注：适当标记重点和难点。 概论概论 瓣膜解剖瓣膜解剖心瓣膜病心瓣膜病 概论概论 瓣膜解剖瓣膜解剖心瓣膜病心瓣膜病 overview A diseased valve may be narrowed (stenosed) or it may fail to close adequately, and thus permit regurgitation of blood.Principal causes of valve disease Valve regurgitationCongenitalAcute rheumatic carditis Chronic rheumatic carditisInfective endocarditisSyphilitic aortitisValve ring dilatationTraumatic valve ruptureSenile degenerationDamage to chordae and papillary muscles Valve stenosisCongenitalRheumatic carditisSenile degenerationMitral stenosis 二尖瓣狭窄二尖瓣狭窄Etiology Most often due to multiple episodes of rheumatic fever resulting in inflammation and scarring on the mitral valve Congenital mitral stenosis (MS) is a rare disease Epidemiology Rare in industrialized countries in patients 40 Very common in developing countries, especially South Asia with severe disease often at early age (20) Mitral StenosisPhysiology/Natural History Normal MVA 4 -6 cm2 Symptoms not apparent until area 1.5 5Moderate 1.0 - 1.55 -10Severe 10 * assumes normal cardiac outputMitral StenosisPhysiology/Natural History LA pressure PV pressure interstitial edema alveolar flooding Adaptations:-pulmonary vascular constriction, intimal hyperplasia, medial hypertrophy reversible pulmonary hypertension fixed pulm htn-downregulation of neuroreceptors, lymphatic drainageMitral StenosisPhysiology/Natural History Latent (subclinical) phase in RHD 20-40 yrs 10 yrs of symptoms before disabling With physically limiting symptoms 10 yr survival 0-15% 10-20% systemic embolism 30-40% develop AF With onset of severe pulm hypertension Mean survival 3 yrsMitral Stenosis: PathophysiologyScarring & fusion of valve apparatusNl valve area: 4-6 cm2Mild mitral stenosis: 2MVA 1.5 cm2 Minimal symptomsMod mitral stenosis 1.0 MVA 1.5 cm2 usually does not produce symptoms at restSevere mitral stenosis MVA 1.0 cm2 left atrial pressure pulmonary venous pressure dyspnea “Atrial” view of mitral valve in patient with rheumatic mitral stenosis.Clinical features (symptoms) Exertional dyspnoea, nocturnal dyspnoea, cough Symptoms of acute pulmonary oedema (especially with pregnancy or AF) Symptoms secondary to arteral/venous emboli, e.g. stroke, haemoptysis, chest pain Symptoms of diminished cardiac output, e.g. fatigueClinical features (signs) Atrial fibrillation Mitral facies Auscultation: loud fist heart sound, opening snap Mid-diastolic murmur Signs of raised pulmonary capillary pressure crepitations, pulmonary edema, effusions Signs of pulmonary hypertension RV heave, loud P2Investigations ECG: left atrial hypertrophy (if not in AF) right ventricular hypertrophy Investigations Chest radiograph -enlarged left atrium -signs of pulmonary venous hypertension 心瓣膜病二心瓣膜病二尖瓣狭窄尖瓣狭窄 右室大.肺动脉突出. 左房扩大. 食道后移左房大Investigations Echo: thickened immobile cusps, reduced valve area, reduced rate of diastolic filling of LV Doppler: pressure gradient across mitral valve, pulmonary artery pressureMitral Stenosis: Complications Atrial dysrrhythmias Systemic embolization (10-25%) Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis Endocarditis Pulmonary infectionsManagement Medical Salt reduction Diuretics Control of heart rate with digoxin Anti-arrhythmic drugs Prevention of thromboemboli with anticoagulants ManagementSurgical Interventional therapy indicated for mitral valve area of 60%) and LVESD (45 mm) are primary predictors of postop survival Clinical features (symptoms) Acute -symptoms of acute pulmonary oedema and reduced cardiac output Chronic -exertional dyspnoea, nocturnal dyspnoes, palpitations (AF, increased stroke volume) -symptoms of diminished cardiac output, e.g. fatigue -symptoms of pulmonary oedema (esp, with pregnancy or AF) -ankle/leg oedema, abdominal swelling (right heart failure)Clinical features (signs) Atrial fibrillation/flutter Cardiomegaly displaced hyperdynamic apex beat Apical pansystolic murmur thrill Soft S1, apical S3 Signs of raised pulmonary capillary pressure crepitations, pulmonary edema, effusions Signs of pulmoanry hypertension may be presentInvestigations Chest radiography -enlarged left atrium -enlarged left ventricle -sings of pulmonary venous hypertension -sings of pulmonary edema (if acute)Investigations ECG -LA hypertrophy (if not AF) -LV hypertrophy Echo -Dilated LA, LV -Dynamic LV (unless LVF predominated) Doppler -Detects and quantifies regurgitationManagement Medical Salt reduction Diuretics Digoxin Vasodilators (ACE inhibitors, nitrates, hydralazine) Management Medical Anticoagulation Anti-arrhythmics Intra-aortic balloon pump (IABP) as temporizing measure before surgery for acute MRManagementSurgical Mitral valve repair or replacement: must be performed before LV function too seriously compromised Aortic Valve DiseaseAortic StenosisAortic InsuffiencyAortic stenosis Etiologies Bicuspid aortic valve (most common congenital anomaly) Calcification of tri-leaflet aortic valve Congenital unileaflet valve Rheumatic fever ( 1.0 25Moderate1.0 - 0.7525 - 50Severe 50 * assumes normal cardiac outputAortic StenosisPhysiologic Principles-Natural History Primary adaptation is concentric hypertrophy Latent phase usually lasts decades Risk of sudden death is very low during this phase Rate of progression ranges from 0-0.3 cm2/yr. (average rate is 0.12 cm2/yr) 50% of patients with severe AS do not progress Cannot predict who will progressAortic StenosisPhysiologic Principles-Natural History Once symptoms develop, average survival is 2-3 yrs With LV systolic dysfunction, there may be increased risk of sudden death and permanent LV dysfunction Ross J Jr, Braunwald E: Aortic stenosis. Circulation 38Suppl V:61, 1968Clinical features (symptoms) Exertional dyspnoea Angina Pulmonary oedema Exertional syncope Sudden deathClinical features (signs) Ejection systolic murmur Slow-rising carotid pulse, reduced pulse pressure Left venticular hypertrophy, thrusting left ventricle Signs of left ventricular failure (crepitation, pulmonary oedemaInvestigations ECG: left ventricular hypertrophy; LBBB Chest radiograph: may be normal. Sometimes enlarged left ventricle and dilated ascending aorta on PA view, calcified valve on lateral view Echo:calcified valve, hypertrophied LV Doppler: estimat of gradient Investigations Cardiac catheterisation -systolic gradient between LV and aorta -post-stenotic dilatation of aorta -regurgitation of aortic valve may be presentN.B. cardiac catheter may only be required to determination if coronary disease is presentManagement Medical Anti-arrhythmics Endocarditis prophylaxis No specific role for medical therapy Mild AS should be followed upManagement Surgical Aortic valve replacement is treatment of choice and is associated with improved survival and LV function even in those with pre-operative LV dysfunction as well as in octogenarians Aortic balloon valvuloplasty is purely palliative and is not associated with improved survival or adequate long-term benefits It should be reserved for patients who cannot tolerate surgery. 经皮主动脉瓣置换术（PAVR)经皮主动脉瓣置换术（TAVI)Aortic regurgitation Etiologies Acute Infective endocarditis Trauma Aortic dissection Etiologies Chronic Primary valvular Rheumatic fever Bicuspid valve Aortic root disease Aortic dissection MarfanAortic Regurgitation Physiologic Principles-Natural History LV faces combined pressure and volume load Primary adaptation is dilatation (eccentric hypertrophy) Since this adaptation takes time, AR classified as acute or chronic Acute AR results in sudden increase in LVEDP pulmonary edema and cardiogenic shockAortic Regurgitation Physiologic Principles-Natural History Latent phase of AR, like AS, may last decades Decompensation when LV systolic function begins to fail Progressive LV dilatation occurs Spherical geometry develops Initially this is reversible LV systolic function and ESD are the most important predictors of postop survival and LV functionAortic Regurgitation Physiologic Principles-Natural History In asymptomatic pts with severe AS and nl LV systolic function, progression is slow 4.3%/yr develop symptoms of LV systolic dysfunction 1.3%/yr progress to LV dysfunction without symptoms pooled data from 7 series. 490 pts with mean follow-up of 6.4 yrsClinical features (symptoms) Mild to moderate AR -Often asymptomatic -Awareness of heart beat, palpitations Severe AR -Symptoms of heart failure -AnginaClinical features (signs) Pulses -large-volume or collapsing pulse -bounding peripheral pulses -femoral bruit (pistol shot)Duroziezs sign -head nodding with pulsede Mussets sing Murmurs -early diastolic murmur -systolic murmur of increased stroke volume -Austin Flint murmur (soft mid-diastolic) Other signs -Thrusting apex, fourth heart sound, enlarged lv -signs of heart failureInvestigations ECG -initially normal, later LV hypertrophy and T wave inversion Chest radiograph -cardiac dilatation, may be aortic dilatation -features of left heart failureinvestigations Echo -Dilated left ventricle -Hyperdymamic ventricle -Fluttering anterior mitral leaflet, Doppler detects reflux Cardiac catheterisation (may not be required) -Dilated LV, aortic regurgitation -Dilated aortic rootManagement Chronic Mild or moderate AR or severe AR in patients with good exercise tolerance and normal LV function can be managed with salt restriction, diuretics, vasodilators Patients with severe AR and symptoms or with evidence of LV dysfunction should be considered for aortic valve replacement 心瓣膜病二心瓣膜病二尖瓣狭窄尖瓣狭窄 闭式分离术和人工瓣膜置换术闭式分离术和人工瓣膜置换术Management Acute Medical emergency requiring urgent surgical replacement of damaged aortic valve IABP contra-indicated (would increase AR) Tricuspid ValveTricuspid InsufficiencyTricuspid stenosisTricuspid Insufficiency: General Most commonly associated with right ventricular dilatation and hypertrophy (Pulm HTN) Can result from IE, MI, trauma, congenital Murmur quality similar to MR, along the LSB with inspiration Rarely needs surgery Tricuspid StenosisTricuspid Stenosis: Etiology, Symptoms, PDX & Tx Almost always a result of Rheumatic fever. Rarely assoc. w/carcinoid tumor, R. atrial myxoma Symptoms of fatigue and dyspnea Diastolic murmur heard best along the LLSB Tx: surgical, Can salt restrict, diurese to hepatic congestion.思考题 心脏瓣膜病的诊断方法？ 瓣膜听诊特点。Thank you