内科学：心脏瓣膜病课件.ppt

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1、1Valvular Heart Disease心脏瓣膜病心脏瓣膜病2目目 的的 要要 求求v掌握常见瓣膜病变病理解剖病理生理、临床表现、诊断方法v熟悉心脏瓣膜病治疗原则3 心脏血流动力学示意图心脏血流动力学示意图4Normal MS5Normal MS67GeneralConsideration以下因素以下因素Inflammation炎症炎症Degeneration退化退化deformation畸形畸形Trauma 创伤创伤以下瓣膜结构以下瓣膜结构改变改变Leaflet 瓣叶瓣叶valve ring瓣环瓣环papillary muscle乳头肌乳头肌 瓣膜狭窄瓣膜狭窄瓣膜关闭瓣膜关闭不全不全&

2、Ischemic necrosis 缺血坏死缺血坏死Chordae tendineae 腱索腱索8心脏瓣膜病病因心脏瓣膜病病因v风湿性心脏病风湿性心脏病(风心病、风心病、rheumatic heart disease)风湿性炎症过程所致的瓣膜损害风湿性炎症过程所致的瓣膜损害主要累及主要累及4040岁以下人群岁以下人群我国常见的心脏病之一我国常见的心脏病之一v 瓣膜粘液样变性和老年人瓣膜钙化日益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

3、 due to rheumatic heart disease9风湿热风湿热 acute articular rheumatism全身结缔组织免疫性疾病全身结缔组织免疫性疾病乙型乙型A族溶血性链球菌族溶血性链球菌主要表现：主要表现：心脏炎心脏炎游走性关节炎游走性关节炎皮肤环形红斑皮肤环形红斑皮下结节皮下结节舞蹈病舞蹈病10Brief introductionBicuspid 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

4、脉瓣最常受累为二尖瓣，其次为主动脉瓣11Mitral Valve Disease Mitral stenosis Mitral incompetenceClassification12Part IMitral stenosis13MitralStenosisNaturalHistoryProgressive,life long diseaseUsually slow&stable in the early yearsProgressive 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14MitralStenosi

5、sNaturalHistoryseveral years latency fever to symptom onsetAdditional 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15Mitral Stenosis:Etiology&pathologyMost 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

6、 fever多数成年患者：二狭由风湿热引起多数成年患者：二狭由风湿热引起2/32/3是女性，是女性，1/21/2无风湿热病史无风湿热病史161718MitralStenosis:Etiology&pathologyPathological change is inflammation and thickening of leaflet tips that restricts the motion of the tipsChronic MS LAE&calcification，LA embolization especially accompanied with AF病理改变：炎症及瓣叶增厚粘连

7、限制瓣膜活动病理改变：炎症及瓣叶增厚粘连限制瓣膜活动慢性二狭慢性二狭 左房增大及钙化，房颤时血栓形成左房增大及钙化，房颤时血栓形成19二尖瓣狭窄二尖瓣狭窄隔膜型隔膜型：瓣膜交界处粘：瓣膜交界处粘连和连和/或瓣膜本身增厚或瓣膜本身增厚但瓣膜尚有一定的弹性但瓣膜尚有一定的弹性能自由活动能自由活动漏斗型：漏斗型：瓣膜极度增厚瓣膜极度增厚腱索、乳头肌粘连缩短腱索、乳头肌粘连缩短瓣膜活动显著受限瓣膜活动显著受限 瓣口呈瓣口呈“鱼口鱼口”状，常伴二状，常伴二闭闭病理解剖与病理生理病理解剖与病理生理20二尖瓣狭窄二尖瓣狭窄病理解剖与病理生理病理解剖与病理生理正常：正常：4-6cm4-6cm2 2 轻度：轻度

8、：1.5cm1.5cm2 2中度中度:1:11.5 cm1.5 cm2 2重度重度:1 cm:1 cm2 221Mitral Stenosis:Pathophysiology(1.5cm2)Moderate StenosisSevere Stenosissevere pulmonary venous congestionmaintain normal flow across the valvemaintain normal cardiac outputshorten diastoleincrease mitral flow rate&Right heart failure22Pathophys

9、iologicalprogressionofmitralstenosisRV enlargementpulmonary venous pressurepulmonary venous congestionLA pressure elevationMSLAEpulmonary capillary pressure elevationSlowing LV fulfillmentpulmonary arterial pressure elevationRight heart failure二尖瓣狭窄二尖瓣狭窄左室充盈减慢左室充盈减慢左房压力增高左房压力增高左房增大左房增大肺静脉淤血肺静脉淤血肺毛细血

10、管压力增高肺毛细血管压力增高肺静脉压力增高肺静脉压力增高肺动脉压力增高肺动脉压力增高右室增大右室增大右心衰右心衰23二狭病理生理 左房压力左房压力三三部部曲曲肺循环压力肺循环压力右心室压力右心室压力LVRVRALAPALung24Manifested after moderate stenosis中度狭窄方出现症状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劳累后

11、呼吸困难通常为首发症状Clinical manifestation:Symptoms25Clinical manifestation:Symptoms (Area of mitrial valve 1.5 2)dyspnea -exertion -resting -orthopnea-paroxysmal nocturnal dyspnea（瓣口面积（瓣口面积1.51.52 2）l 呼吸困难呼吸困难 最常见早期症状最常见早期症状 劳力性劳力性静息时、端坐呼吸、阵发静息时、端坐呼吸、阵发性夜间呼吸困难性夜间呼吸困难 肺水肿肺水肿26HemoptysisMassive hemoptysisSupt

12、um with blood,often with PND or coughPink,frothy suptumPulmonary embolism with hemoptysisCoughHoarsenessClinical manifestation:Symptoms咯血咯血咯大量鲜血咯大量鲜血痰中带血（夜间阵痰中带血（夜间阵发性呼吸困难）发性呼吸困难）粉红色泡沫痰粉红色泡沫痰肺栓塞伴咯血肺栓塞伴咯血咳嗽咳嗽声嘶声嘶27咯血咯血：1 1）鲜血）鲜血(支气管静脉破裂支气管静脉破裂)2 2）血性痰）血性痰(微血管破裂微血管破裂)3 3）粉红色泡沫痰）粉红色泡沫痰(急性肺水肿急性肺水肿)4 4）暗

13、红色血暗红色血(肺梗死伴咯血肺梗死伴咯血)咳嗽：咳嗽：支气管粘膜淤血和左房增大支气管粘膜淤血和左房增大声嘶：声嘶：扩大左房压迫左喉返神经扩大左房压迫左喉返神经 28Clinical manifestation:SignsMitral face in severe MS 重度重度MSMS常有常有 “二尖瓣面容二尖瓣面容 ”双颧绀红双颧绀红293032S1 is accentuated S1亢进亢进OS after aortic valve closure 主动脉关闭后开瓣音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心尖区低

14、调舒张期杂音隆隆样或滚筒样，舒张中晚期，递减隆隆样或滚筒样，舒张中晚期，递减-递增型，伴舒张期震颤递增型，伴舒张期震颤In severe MS with low flow-S1,OS&rumble may be inaudible重度重度二狭时二狭时S1S1减弱、开瓣音消失减弱、开瓣音消失S1S2OSS1Clinical manifestation:SignsSign of MS33Pulmonary hypertension&RVEDispersion of beat at apexRV liftP2 loudness and splitGraham Steell murmur relati

15、ve TI with RVEClinicalmanifestation:Signs肺动脉高压及右室肺动脉高压及右室 扩大扩大心尖搏动弥散心尖搏动弥散右室抬举感右室抬举感P P2 2亢进及分裂亢进及分裂Graham Steell Graham Steell 杂音杂音:相对性肺闭，舒张期相对性肺闭，舒张期 杂音杂音相对性三闭伴右室大相对性三闭伴右室大34Mitral Stenosis:Laboratory ExaminationX-ray左房大左房大右室增大右室增大主动脉结小主动脉结小肺动脉段突肺动脉段突35X 线 表 现 梨形心36胸片后前位（左图）两肺门大而模糊。心脏如梨状。心尖位于横膈胸片后

16、前位（左图）两肺门大而模糊。心脏如梨状。心尖位于横膈之上。主动脉球大小如常。左侧位（右图）示食管左心房段有明显之上。主动脉球大小如常。左侧位（右图）示食管左心房段有明显压迹。食管与心后缘间有一透亮三角区。表明无左心室增大。压迹。食管与心后缘间有一透亮三角区。表明无左心室增大。37Mitral Stenosis:Laboratory Examination电轴右偏、右心室肥厚电轴右偏、右心室肥厚重度尖瓣狭窄可有重度尖瓣狭窄可有“二尖瓣二尖瓣波波”，P P波宽度波宽度0.12S0.12S可表现为心房纤颤可表现为心房纤颤ECG38心电图示心房纤颤，心电图示心房纤颤，P P波消失，心律绝对不规整波消失

17、，心律绝对不规整心电图还提示右室肥厚，电轴右偏，侧壁导联心电图还提示右室肥厚，电轴右偏，侧壁导联S S波深大。波深大。心电图上同时出现心房纤颤和电轴右偏提示心电图上同时出现心房纤颤和电轴右偏提示MSMS的可能性大的可能性大 Xiangya-3 ECG3940MitralStenosis:LaboratoryExaminationEchocardiographyDoppler echocardiography超声可以确诊及评估严重程度舒张期前叶呈圆拱状舒张期前叶呈圆拱状后叶活动度减少后叶活动度减少交界处粘连融合交界处粘连融合瓣叶增厚和瓣口面积缩小瓣叶增厚和瓣口面积缩小41MitralStenos

18、is:LaboratoryExaminationM-mode echocardiographyEchocardiography超声可以确诊及评估严重程度42TheorificeofthestenoticMVcanbevisualizedand.measuredmitralvalveareaisapproximately1.1cm2可见狭窄的瓣膜孔，经测定为1.1 cm243二尖瓣前叶活动双二尖瓣前叶活动双峰消失，舒张早期峰消失，舒张早期形成形成E峰，形成峰，形成“城城墙样墙样”改变，二尖改变，二尖瓣前后叶同向运动瓣前后叶同向运动血栓血栓44Mural thrombosis in LA附壁血栓附

19、壁血栓45Mitral Stenosis:Laboratory ExaminationCatheterization 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 indicatedCardiac Catheteriza

20、tion导管用于术前评估左室功能及肺动脉压导管用于术前评估左室功能及肺动脉压46Mitral Stenosis:Laboratory ExaminationIt is It is recommended for the patients who recommended for the patients who have a discrepancy between clinical have a discrepancy between clinical and echocardiographic findingsand echocardiographic findingsCardiac Cath

21、eterization用于临床表现与超声结果不符时用于临床表现与超声结果不符时47MS:Diagnosis Low pitch DM at the apex 心尖区低调舒张期杂音心尖区低调舒张期杂音X-ray,ECG:LAE胸片、心电图示左房大胸片、心电图示左房大UCG:final diagnosis 超声：确诊超声：确诊DM might be lowered or disappeared if AF房颤时舒张期杂音减弱甚至消失房颤时舒张期杂音减弱甚至消失 心尖部舒张期心尖部舒张期隆隆样杂音隆隆样杂音X线线/心电图心电图示左心房增大示左心房增大超声心动图特征超声心动图特征48Different

22、ial diagnosisBlood 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 AImucous tumor in LA：、二尖瓣口血流量增加致相对性二尖瓣狭窄、二尖瓣口血流量增加致相对性二尖瓣狭窄 （重度贫血、（重度贫血、左血右分流先心、甲亢等）左血右分流先心、甲亢等）、A

23、ustin-Flint杂音杂音中重度主动脉瓣关闭不全患者，由于舒张期血流由主动脉反流入左心室，将二尖瓣前叶冲起，造成相对性二尖瓣狭窄的舒张期隆隆样杂音，称为AustinFlint杂音。杂音特点为柔和,递减型舒张中晚期杂音,无震颤.、左房粘液瘤、左房粘液瘤49Transthoracicechocardiogramdemonstratingalargeatrialmyxoma.Themyxoma(Myx)fillstheentireleftatriuminsystole(panel A)andprolapsesacrossthemitralvalveandintotheleftventricle(

24、LV)duringdiastole(panel B).50MitralStenosis:ComplicationsAtrial fibrillationAcute pulmonary edemaSystemic embolization Right heart failure Endocarditis Pulmonary infections房颤:早期急性肺水肿:严重MS血栓栓塞：晚期常见并发症右心衰竭:晚期，发生率20%感染性心内膜炎:少见肺部感染:常见51Mitral Stenosis:TherapyGeneral treatment Avoiding from factors cause

25、 cardiac overload as follow：Infection、anemia、salty diet、exhaustingMedicalTreat rheumatic activity Diuretics Endocarditis prophylaxis 一般治疗一般治疗、预防风湿热复发，长期甚至终生、预防风湿热复发，长期甚至终生、预防风湿热复发，长期甚至终生、预防风湿热复发，长期甚至终生、预防感染性心内膜炎、预防感染性心内膜炎、预防感染性心内膜炎、预防感染性心内膜炎、无症状：避免剧烈活动，定期复查、无症状：避免剧烈活动，定期复查、无症状：避免剧烈活动，定期复查、无症状：避免剧烈活动

26、，定期复查、呼吸困难者：减少体力活动，限盐，利尿，适当强心，消除诱、呼吸困难者：减少体力活动，限盐，利尿，适当强心，消除诱、呼吸困难者：减少体力活动，限盐，利尿，适当强心，消除诱、呼吸困难者：减少体力活动，限盐，利尿，适当强心，消除诱因因因因52Mitral Stenosis:Therapy并发症的处理并发症的处理 1 1 大量咯血：端坐、镇静、利尿大量咯血：端坐、镇静、利尿 2 2 急性肺水肿：处理原则同急性左心衰急性肺水肿：处理原则同急性左心衰避免使用扩动脉药，选用硝酸酯类药避免使用扩动脉药，选用硝酸酯类药正性肌力药对正性肌力药对MSMS的肺水肿无益的肺水肿无益3 3 房颤房颤4 4 预防

27、栓塞预防栓塞5 5 右心衰竭：限钠、利尿右心衰竭：限钠、利尿6 6介入治疗：介入治疗：瓣膜弹性良好，瓣膜弹性良好，强、可闻及开瓣音、瓣叶无明显钙化强、可闻及开瓣音、瓣叶无明显钙化左室无明显扩大左室无明显扩大左房无附壁血栓左房无附壁血栓53Mitral Stenosis:TherapyBalloon valvuloplasty 球囊扩张术球囊扩张术 Effective long term improvement能长期改善症状能长期改善症状SurgicalMitral commissurotomy 瓣膜分离术瓣膜分离术Mitral Valve Replacement 瓣膜置换术瓣膜置换术（生物瓣、

28、（生物瓣、机械瓣）机械瓣）54Inoueballoontechniqueformitralballoonvalvotomy.A.Aftertransseptalpuncture,thedeflatedballooncatheterisadvancedacrosstheinter-atrialseptum,thenacrossthemitralvalveandintotheleftventricle.B.Theballoonistheninflatedstepwisewithinthemitralorifice.5556扩张前扩张前扩张后扩张后57各种人工心脏瓣膜各种人工心脏瓣膜58带支架生物瓣

29、带支架生物瓣59Mitral Stenosis:Prognosis 预后预后Asympotomic:84%Mild sympotom:42%Moderate&severe sympotom:15%Heart failure:62%Embolism 栓塞栓塞:22%Infectious endocarditis心内膜炎心内膜炎:8%Average duration from occurrence of symptoms to entire disable 平均发病时间平均发病时间7.3 Years10 years survival rateReason for death60Part IIMit

30、ral Incompetence61Mitral incompetenceEtiology&pathologyValvular-leafletsRheumaticMyxomatous MVIEHCMCongenitalAnnulusLVE or left heart failureDegenerativeCalcification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 老年二尖瓣环及瓣下老年二尖瓣环及瓣下区钙化区钙化62ChordaeCongenitalAcquairedPapillary MusclesIchemiaNecrosisTrauma腱索腱索先天性

31、先天性获得性获得性乳头乳头肌肌缺血缺血坏死坏死外伤外伤Mitral incompetenceEtiology&pathology63Mitral Incompetence:PathophysiologyAcute Mitral IncompetenceChronic Mitral Incompetence64AABack flow from LV&PV rush into LABBLA&LV volume overloadC CPulmonary congestion,edemaDDPulmonary hypertension,RHF AcutepressureD血流返流至血流返流至LA，充盈

32、，充盈LV前负荷前负荷 LV、LA压压肺淤血、肺水肿肺淤血、肺水肿 肺高血压肺高血压65Chronic left heart failureBackflowLAE Pulmonary hypertensionRight heart failurePulmonary congestionChronic LV volume overloadCompensatory 代偿代偿Decompensation 失代偿失代偿(increased LV wall tension)Chronic持续前负荷持续前负荷左心衰左心衰LA压和压和LV舒张末压舒张末压肺肺淤血、肺动脉高压淤血、肺动脉高压右心衰右心衰 66

33、慢性容量负荷代偿慢性容量负荷代偿LVLV舒张末期容量舒张末期容量 代偿性离心性肥大代偿性离心性肥大LVLV收缩期部分血排入收缩期部分血排入LALA代偿期心输出量代偿期心输出量COCO，超正常，超正常扩大扩大LALA、LVLV适应容量负荷适应容量负荷 舒张末压不致明显舒张末压不致明显 不出现肺淤血不出现肺淤血持久负荷，引起左心衰，持久负荷，引起左心衰，COCO 左房压和左心室舒张末压左房压和左心室舒张末压 PAPA高压、右心衰竭高压、右心衰竭Chronic Mitral incompetence:Pathophysiology67MitralincompetenceClinicalmanifes

34、tationSystemic embolization 栓塞Hemoptysis 咳血Pulmonary hypertension肺性高血压Fatigue 乏力Dyspnea&Orthopnea 呼吸困难 Clinical manifestation also present different feature with various rate of progressionIt is Similar to MS68Mitral incompetenceClinical manifestation 急性急性轻度仅轻微劳力性呼吸困难轻度仅轻微劳力性呼吸困难严重很快发生急性左心衰竭，休克严重很快发

35、生急性左心衰竭，休克 慢性慢性轻度可终身无症状轻度可终身无症状,通过通过LALA扩张代偿扩张代偿严重严重心输出量心输出量COCO，疲乏，肺淤血症状出现晚疲乏，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，晚期出现左心衰竭二尖瓣脱垂：多无症状，晚期出现左心衰竭69体体 征（慢性）征（慢性）v心尖搏动：高动力型，LV 时向左下移位v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70v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

36、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体体 征（慢性）征（慢性）72Acute mitral incompetence:SignsLoud P2S4Diastolic rumble murmurS3 presentSystolic murmur may not be pan-systolicLV may be hyperdynamicv心尖搏动为高动力型心尖搏动为高动力型vS2S2肺动脉瓣成分亢进肺动脉瓣成分亢进v心尖区心尖区S4S4常

37、见常见v非全收缩期杂音，低调，非全收缩期杂音，低调，呈递减呈递减v严严重重反反流流心心尖尖区区S3S3和和短短促促舒舒张期隆隆样杂音张期隆隆样杂音73Mitral incompetence Laboratory Examination Acute mitral incompetence:Severe pulmonary congestion,oedema Chronic mitral incompetence:LV,LA pulmonary vascularityMitral annulus calcificationX-ray急性者急性者心影正常或心影正常或LALA轻度轻度 伴明伴明显肺淤血

38、，肺水肿显肺淤血，肺水肿慢性重度反流慢性重度反流LALA、LVLV：肺淤血和间质肺淤血和间质性肺水肿性肺水肿二尖瓣环钙化为致密而二尖瓣环钙化为致密而粗粗C C形阴影形阴影74急性急性MR肺水肿肺水肿X线征象线征象75胸正位（左）示两肺充血。心脏以左心室扩大为主胸正位（左）示两肺充血。心脏以左心室扩大为主.心尖心尖下沉侧位（右）示食道左心房段有明显压迹及后移。下沉侧位（右）示食道左心房段有明显压迹及后移。76ECGAcutemitralincompetenceUsuallynormalEKG,sinustachycardiapresentChronicmitralincompetenceLAen

39、largementAtrialfibrillationLVH(50%pts.WithsevereMR)RVH(15%)Combinedhypertrophy(5%)ECG features ECG features 心电图心电图v急性急性心电图可正常，心电图可正常，窦性心动过速常窦性心动过速常见见v慢性重度慢性重度LA LA ，LVLV肥厚和肥厚和非特异性非特异性ST-TST-T改改变变RVRV肥厚征，心房肥厚征，心房颤动常见颤动常见77Mitral Incompetence Laboratory ExaminationFunctionIdentify etiology&severity of

40、 MREvaluation post mitral valve replacement Establish cardiac status after change in symptomsEchocardiographyAssess LV function&dimensionsAnnual surveillance of LV functionEstimated EF&LVESD in asymptomatic severe MR78EchocardiographySevere mitral regurgitation due to a dilated annulus and abnormal

41、mitral valve 7980彩色多普勒彩色多普勒 测量返流束面积与左房面积测量返流束面积与左房面积轻轻中中重重返流束面积返流束面积4cm4cm2 24-8cm4-8cm2 28cm8cm2 2返流束面积返流束面积/左房面积左房面积20%20%局限于局限于二尖瓣二尖瓣20-40%20-40%左房腔左房腔中部中部40%40%心房顶心房顶部部81Mitral Incompetence Laboratory ExaminationCardiac Catheterization“Golden Standard”for estimating severity of MI Case ICase II8

42、2Mitral Incompetence:DiagnosisDyspneaApex region systolic murmurChest X ray display heart maymay 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，心尖突发呼吸困难，心尖区收缩期杂音，区收缩期杂音，X X线心线心影不大

43、影不大,肺淤血明显和肺淤血明显和有病因可寻，如二脱、有病因可寻，如二脱、感染性心内膜炎、心感染性心内膜炎、心梗、瓣膜置换术后，梗、瓣膜置换术后，诊断不难诊断不难急性者急性者83Mitral Incompetence:Diagnosis心尖区有典型心尖区有典型杂音伴左心房杂音伴左心房室增大，诊断室增大，诊断可成立可成立确诊有赖超声确诊有赖超声心动图心动图Systolic murmur（apex region）LA&LV enlargementDiagnosis depends on UCG Chronic慢性者慢性者84鉴别诊断v三尖瓣关闭不全三尖瓣关闭不全v室间隔缺损室间隔缺损v胸骨左缘收缩期

44、喷射性杂音胸骨左缘收缩期喷射性杂音左或右心室流出道梗阻左或右心室流出道梗阻主动脉瓣狭窄主动脉瓣狭窄肺动脉瓣狭窄肺动脉瓣狭窄肥厚型梗阻型心肌病肥厚型梗阻型心肌病健康人的无害性杂音健康人的无害性杂音以上情况有赖心超确诊以上情况有赖心超确诊Mitral Incompetence:Differential DiagnosisTricuspid insufficiencyinterventricular septal defectsystolic ejection murmurs on left sternal border 85MitralIncompetence:Complications并发症AB

45、CDEComplicationsComplicationsAtrial fibrillation房颤房颤Systemic Embolization血栓血栓Congestive heart failure心衰心衰心内膜炎心内膜炎Endocarditis二尖瓣下垂二尖瓣下垂Mitral valve prolapserelated Complications86Mitral Incompetence:ManagementAcuteTo lower pulmonary vein pressure,increase CO and surgical treatment急性急性MI降低肺降低肺V V压，增加

46、心输出量（硝普纳、压，增加心输出量（硝普纳、利尿剂）和纠正病因利尿剂）和纠正病因87DiureticsVasodilatorsPositive Inotropic AgentsNeuro-hormonal Cytokine InhibitorsGeneral therapy for cardiac dysfunctionChronic MI 慢性慢性MIMI内科治疗内科治疗风心病需抗风湿并预防风风心病需抗风湿并预防风湿热湿热无症状、心功能正常者无无症状、心功能正常者无需特殊治疗，但应随访需特殊治疗，但应随访AFAF处理同处理同MSMS，仅控制室率，仅控制室率心力衰竭心力衰竭Mitral Inc

47、ompetence:Management88MitralIncompetence:ManagementMitral Valve SurgeryOnly effective treatment is valve repair/replacementReduces morbidity and mortality from severe MIOperation Should be performed before onset of severe symptoms外科治疗外科治疗 根本措施根本措施，发生不可逆发生不可逆LVLV功功能不全之前，能不全之前，二尖瓣修补术二尖瓣修补术人工瓣膜置换术人工瓣膜置

48、换术89外科治疗人工瓣膜置换术 为主要手术方法。对于无症状且左室收缩功能正常者，密切随访；有症状者，应在左室收缩末期指数50ml/m2、左室射血分数0.5和平均肺动脉压20mmHg之前或当左室收缩末期内径45mm、左室左室收缩末期指数为50ml/m2时手术治疗。二尖瓣修复术90Prognosis Prognosis 预后预后v急性：急性：严重返流伴血流动力学不稳，不严重返流伴血流动力学不稳，不 及时手术干预，死亡率极高及时手术干预，死亡率极高v慢性：慢性：慢性重度慢性重度MI确诊后内科治疗确诊后内科治疗5 5年存年存 活率活率80%80%，1010年存活率年存活率60%60%单纯二脱无明显反流

49、，预后良好单纯二脱无明显反流，预后良好 年龄年龄5050岁、明显杂音、反流、房岁、明显杂音、反流、房 室增大、瓣叶长而厚，预后差室增大、瓣叶长而厚，预后差91Part IIIAortic Stenosis92AorticStenosisEtiology&pathologyCongenitalabnormalityiscommon先天性畸形为最常见原因RHDanddegenerationwithcalcification风心病、退行性变、钙化其次Normalaorticvalve“Normal”geriatriccalcificvalve老年钙化Congenitalbicuspidvalveab

50、normality先天性RheumaticAorticStenosis 风心病93病因和病理v风心病：多伴关闭不全，二尖瓣损害v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v退行性老年钙化性主动脉瓣狭窄v其他少见原因:大的赘生物阻塞瓣口94先先天天性性二二叶叶瓣瓣畸畸形形95主主动动脉脉瓣瓣钙钙化化969798AorticStenosis:PathophysiologyNormal aortic valve area 3.0cm2 Mild stenosis 1.5-2.5 cm2 Moderate stenosis 1.0-1.5 cm2 Severe