瓣膜疾病讲稿不漂亮课件

Sept 21, 2001,Principles of Clinical Medicine OPTH 641 Valvular Heart Disease,Cecils: pp. 69-78 Handout: to follow Slides: On Web Alan J. Hunter, MD Assistant Professor of Medicine Director; Hospitalist Program,Sept 21, 2001,Valvular Heart Disease,Objectives Recognize murmur characteristics & valvular heart disease that suggest the need for further evaluation. Recognize the natural history of the common valvular heart diseases. Recognize the importance of prophylaxis for endocarditis.,Sept 21, 2001,Introduction: Valvular Heart Disease,Historically the principle etiology was 20 to rheumatic fever. Rheumatic Fever Immune medicated syndrome Group A -hemolytic streptococci pharyngitis “Strep throat” Peak age 5-15 y/o RARE in USA, (recent outbreaks however) Syndrome-diagnosed by Criteria,Sept 21, 2001,Introduction: Valvular Heart Disease Jones Criteria (Rheumatic Fever),Carditis Pericarditis Cardiomegaly CHF Mitral or aortic insufficiency or acute “Valvulitis” Erythema marginatum (rash) Subcutaneous nodules Chorea (Syndenhams C) movement disorder (3%) Poly-arthritis,Sept 21, 2001,Introduction: Valvular Heart Disease,“RF” still number #1 cause in developing countries. In the industrial world other causes now predominate. Endocarditis Calcific aortic disease Myocardial infarction,Sept 21, 2001,Murmurs,Murmur = Turbulence! (flow) “Pathologic” or “Innocent” “Maneuvers” BASICALLY to differentiate “Left” from “Right” sided & Stenosis vs regurgitant murmurs.,Sept 21, 2001,Innocent Murmurs,Common in asymptomatic adults Characterized by; Grade I II LSB Systolic ejection pattern,Nl intensity & splitting of second sound (S2) No other abnormal sounds or murmurs No evidence of LVH, and no with Valsava,S1 S2,Sept 21, 2001,Murmurs: Who needs referral/eval? (Best Evidence For),Symptoms Dyspnea Edema Chest pain Syncope Quality & Timing of Murmurs VERY loud +/or Diastolic murmurs,Sept 21, 2001,Common Valvular Heart Diseases,Classification By timing & “morphology” in the Cardiac Cycle My favorite way,Sept 21, 2001,Common Valvular Heart Diseases: (By murmur timing/quality),Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis,S1 S2 S1,Sept 21, 2001,Common Valvular Heart Diseases,Classification By timing & “morphology” in the Cardiac Cycle My favorite way Anatomically Will do today,Sept 21, 2001,Aortic Valve Disease Aortic Stenosis Aortic Insuffiency,Sept 21, 2001,Aortic Stenosis: Etiology,Congenital bicuspid valve is the most common abnormality Rheumatic heart disease and degeneration with calcification are found as well,Normal Bicuspid Ao V “Normal” geriatric calcific valve,Sept 21, 2001,Aortic Stenosis: Symptoms,Cardinal Symptoms Chest pain (angina) A “Demand” “supply” problem Syncope ( fainting) Dyspnea on exertion & rest Other signs of LV failure (RV failure, edema),Sept 21, 2001,Aortic Stenosis: Physical Findings,Intensity DOES NOT predict severity “Diamond” shaped, systolic crescendo-decrescendo Decreased, delay & prolongation of pulse amplitude S4 (with left ventricular hypertrophy) S3 (with left ventricular failure),S1 S2 S1 S2 Mild-Moderate Severe,Sept 21, 2001,Aortic Stenosis: Prognosis,Heart failure reduces life expectancy to less than 2 years Angina and syncope reduce life expectancy between 2 and 5 years,Tx: Valve replacement for severe aortic stenosis,Sept 21, 2001,Aortic Insufficiency: Etiology,Any conditions resulting in incompetent aortic leaflets Rheumatic heart disease Dilated cardiomyopathy (e.g. hypertension) Syphilis (chronic aortitis) Collagen disorders (e.g. Marfans) Connective tissue disorders E.g. ankylosing spondylitis, rheumatoid arthritis, Reiters syndrome) Cystic medial necrosis Acute AI: aortic dissection, infective endocarditis,Sept 21, 2001,Aortic Insufficiency: Symptoms,Dyspnea, orthopnea, PND, and chest pain. Nocturnal angina exertional angina ( cardiac filling, thus coronary aa flow) Thus with extreme reductions in diastolic pressures (e.g. 40) may see angina,Sept 21, 2001,Aortic Insufficiency: Physical Exam,Widened pulse pressure Syst. diast.= pulse pressure High pitched, blowing, decrescendo diastolic murmur at LSB (end-expiration & leaning forward) Plethora of named signs assoc. w/ pulse pressure: De Mussets S. head bobbing “Pistol shot” Loud shot over fem. arteries Quinckes S Pulsations in the nail bed (useless”) Corrigans Pulse Water hammer pulse (Lg,rapid) MANY others,S1 S2 S1,Sept 21, 2001,Aortic Insufficiency: Natural History,Asymptomatic %/Y Normal LV function (good prognosis) Progression to symptoms or LV dysfunction 10,Bonow RO, et al, JACC. 1998;32:1486.,TX: Medical Surgery BEFORE LV dysfunction,Sept 21, 2001,Mitral Valve Disease Mitral Insufficiency (Mitral Regurgitation) Mitral Valve Prolapse Mitral Stenosis,Sept 21, 2001,Mitral Insufficiency: Etiology,Rheumatic etiology in males females Chronic rheumatic heart disease 33% patients May also occur as a congenital anomaly ANYTHING THAT LV enlargement Acute insufficiency may occur 20; Infective endocarditis Acute myocardial infarction Trauma,Sept 21, 2001,Mitral Insufficiency: Symptoms,Fatigue Exertional dyspnea, and orthopnea (more prominent with chronic, severe MR) Hemopytsis and system embolization (occur less frequently in MR),Sept 21, 2001,Mitral Insufficiency: Physical Exam,Apical holosystolic murmur Radiation to the axilla Palpable thrill at cardiac apex,S1 S2 S1,Treatment Preload Cardiac Output Valve repair with severe MR or refractory symptoms,Sept 21, 2001,Mitral Valve Prolapse,Sept 21, 2001,Mitral Valve Prolapse: Epid-etiology,Affects 5-10% of population Most common cause of isolated severe MR Females males; Ages of 14 and 30years Strong hereditary component (? Autosom. Dom) 20 to in-opposition of the bicuspid mitral valve. Results form diverse pathologic conditions, but cause is unknown in a majority of pts,Sept 21, 2001,Mitral Valve Prolapse: Symptoms,Majority are asymptomatic for entire life Palpitations Chest pain (atypical). Often substernal, prolonged, poorly related to exertion, and rarely resembles typical angina Syncope,Sept 21, 2001,Mitral Valve Prolapse: Complications,Arrhythmias (Usu. PVC, PSVTVT) Transient cerebral ischemic (embolic rare) Infective endocarditis (if assoc w/ MR) Sudden death (rare),Sept 21, 2001,Mitral Valve Prolapse: Physical Exam,Most important finding: mid late systolic click. Acute tensing of the mitral valve chordae Variable murmurs: high pitched late systolic crescendo-decrescendo murmur, Occasionally “whooping” or “honking” at the apex,S1 C S2,Sept 21, 2001,Mitral Valve Prolapse: Treatment,Reassurance Asymptomatic pts w/o sev MR or arrhythmia. Follow-up q 2-4 years, with ECHO Beta blocker treatment for atypical chest pain Infective endocarditis prophylaxis with Systolic murmur &/or Typical echocardiagraphic findings Men definitely! Women? No consensus. Severe sx (e.g. MR) Rxd as mitral insufficiency.,Sept 21, 2001,Mitral Stenosis,Sept 21, 2001,Mitral Stenosis: Etiology,Primarily a result of rheumatic fever ( 99% of MVs surgery show rheumatic damage ) Rarely congenital Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Two-thirds of all patients with MS are female.,Sept 21, 2001,Mitral Stenosis: Pathophysiology,Scarring & fusion of valve apparatus Nl valve area: 4-6 cm2 Mild mitral stenosis: MVA 1.5 cm2 usually does not produce symptoms at rest Severe mitral stenosis MVA 1.0 cm2 left atrial pressure pulmonary venous pressure dyspnea,“Atrial” view of mitral valve in patient with rheumatic mitral stenosis. Fig 46-1, Braunwald, 5th Ed, 2000.,Sept 21, 2001,Mitral Stenosis: Symptoms,Cough, palpitations, chest pain, orthopnea, PND, pulmonary edema, hemoptysis Worsened by condns that cardiac output. Extreme exertion Excitement Fever Severe anemia Paroxysmal tachycardia Sexual intercourse Pregnancy Thyrotoxicosis,Sept 21, 2001,Mitral Stenosis: Physical Exam,First heart sound (S1) is accentuated and snapping Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus rhythm),S1 S2 OS S1,Sept 21, 2001,Mitral Stenosis: Natural History,Progressive, lifelong disease, Usu. Slow & stable in the early years. Progressive acceleration in the later years 20-40 year latency from rheumatic fever to symptom onset. Additional 10 years before disabling symptoms,Sept 21, 2001,Mitral Stenosis: Complications,Atrial dysrrhythmias Systemic embolization (10-25%) Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis Endocarditis Pulmonary infections,Sept 21, 2001,Mitral Stenosis: Atrial Dysrrhythmias,Premature contractions Paroxysmal tachycardias Atrial flutter and/or fibrillation freq. in pts with mod-severe MS for several years A fib develops in 30% to 40% of pts w/symptoms,Sept 21, 2001,Mitral Stenosis: Complications,Systemic embolization (esp. stroke) Occurs in 10-20% of patients with MS Significantly in pts with atrial fibrillation Risk of embolization is related to Age Presence of atrial fibrillation Previous embolic events Hemoptysis Massive: 20 to ruptured bronchial veins (pulm HTN) Streaking/pink froth: pulmonary edema, or infection,Sept 21, 2001,Mitral Stenosis: Treatment,Endocarditis prophylaxis Anticoagulation if concurrent A Fib or prev. embolic event. Valve repair/replacement,Sept 21, 2001,Tricuspid Valve Tricuspid Insufficiency Tricuspid stenosis,Sept 21, 2001,Tricuspid 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 unless assoc w/pulm HTN,Sept 21, 2001,Tricuspid Stenosis,Sept 21, 2001,Tricuspid 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.,Sept 21, 2001,Endocarditis Prophylaxis,Sept 21, 2001,Prophylaxis Recommended: High Risk Cardiac Conditions ,Prosthetic heart valves Previous endocarditis Complex cyanotic heart disease (e.g.); Single ventricle Transposition of the great vessels Tetrology of Fallot Surgically corrected congenital heart disease Systemic-pulmonary shunts Intra-atrial catheters Coarctation, - Agreement is not universal on these conditions,Sept 21, 2001,Most congenital heart disease other then previous or below Acquired valvular heart disease (eg) Rheumatic ht dz, aortic stenosis, aortic insufficiency Hyertrophic cardiomyopathy . Mitral valve prolapse with MR &/or thickened leaflets,Prophylaxis Recommended: Moderate Risk Cardiac Conditions , - Agreement is not universal on these conditions,Sept 21, 2001,Isolated ASD-secundum Surgical repair of; ASD, VSD PDA w/o residua Mitral valve prolapse w/o mitral insufficiency Innocent murmurs H/o Kawasakis w/o valve dysfunction H/o Rheum fever w/o valvular dysfunction Cardiac pacemakers & implantable defibrillators,Prophylaxis Not Recommended: Negligible Risk Cardiac Conditio