【医学ppt课件】心脏瓣膜病

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,以下因素,Inflammation,Degeneration,deformation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,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,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,Normal MS,Normal MS,Mitral Valve Disease,Mitral stenosis,Mitral incompetence,Classification,Part I,Mitral stenosis,Mitral Stenosis Natural 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,Mitral Stenosis Natural 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,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,Mitral Stenosis: Etiology & pathology,Pathological change is inflammation and thickening of leaflet tips that restricts the motion of the tips,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,Mitral Stenosis: Pathophysiology,(1cm2),Mild Stenosis,Almost 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,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,Normal MS,Normal MS,Normal MS,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,Clinical manifestation: Symptoms,(Area of mitrial valve 1.5 2) dyspnea -exertion -resting -orthopnea -paroxysmal nocturnal dyspnea,（瓣口面积1.52） 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,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,Clinical manifestation: Signs,Mitral facies in severe MS 重度MS常有 “ 二尖瓣面容 ” 双颧绀红,Clinical manifestation: Signs,Cardiac signs of MS Normal apex beat Tapping apex-palpable S1 +/- palpable opening snap (OS) Low-pitched diastolic rumbling murmurs at the apex Palpate diastolic thrill,二狭的心脏体征 望诊:心尖搏动正常或不 明显 听诊: S1亢进 开瓣音 心尖区有低调的隆 隆样舒张中晚期杂音 触诊:触及舒张期震颤,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,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,Mitral Stenosis: Laboratory Examination,X-ray,左房大 右室增大 主动脉结小 肺动脉段突,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,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,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,Colorful ejection flow at mitral vavle during diastole,Mural thrombosis in LA,Mitral Stenosis: Laboratory Examination,Catheterization provides assessment of regurgitation, LV function and PAP for determining whether valvotomy is indicated,Cardiac Catheterization,导管用于术前评估左室功能及肺动脉压,Mitral Stenosis: Laboratory Examination,It is recommended for the patients who have a discrepancy between clinical and echocardiographic findings,Cardiac Catheterization,用于临床表现与超声结果不符时,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,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：,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,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,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,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,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,Part II,Mitral Incompetence,Mitral incompetence Etiology & 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,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 incompetence Etiology & pathology,Mitral Incompetence: Pathophysiology,Sorting by rapidity,Text,Text,Text,Acute Mitral Incompetence,Chronic Mitral Incompetence,Back flow from LV & PV rush into LA,LA & LV volume overload,Pulmonary congestion, edema,D,Pulmonary hypertension, RHF,pressure,D,Chronic left heart failure,Pulmonary congestion,Chronic LV volume overload,Compensatory LVDEV,Decompensation (increased LV wall tension),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,Mitral incompetence Clinical manifestation,Systemic embolization,Hemoptysis,Pulmonary hypertension,Fatigue,Dyspnea & Orthopnea,Clinical manifestation also present different feature with various rate of progression,It is Similar to MS,Mitral incompetence Clinical 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,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,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,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,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,Chronic mitral incompetence,ECG Acute mitral incompetence Usually normal EKG,sinus tachycardia present Chronic 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,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,Echocardiography,Severe mitral regurgitation due to a dilated annulus and abnormal mitral valve,flail连枷posterior mitral valve leaflet,彩色多普勒 测量返流束面积与左房面积,Mitral Incompetence Laboratory Examination,Cardiac Catheterization,“Golden Standard” for estimating severity of MI,Case I,Case II,Mitral Incompetence :Diagnosis,Dyspnea Apex region systolic murmur Chest 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,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,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 insufficiency interventricular septal defect systolic ejection murmurs on left sternal border,Mitral Incompetence : Complications,A,B,C,D,E,Complications,Atrial fibrillation,Systemic Embolization,Congestive heart failure,Endocarditis,Mitral valve prolapse related Complications,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,Positive 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,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,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,Part III,Aortic Stenosis,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,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,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,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,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,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,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,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,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,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,Aortic Stenosis: Laboratory Examination,X-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,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,Aortic Stenosis: Laboratory Examination,ECG,Marked LVH pattern 、ST depression 、T wave inversion,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,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,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,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15，单叶瓣畸形多见 1665，先天性二叶瓣钙化可能性大 65，退行性老年钙化性病变多见,Aortic Stenosis Diagnosis & Differential Diagnosis,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),Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis,S1 S2 S1,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,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,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,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，中重度612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,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,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,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%,Part VI,Aortic Incompetence,病因与病理,主动脉瓣和（或）主动脉根 部疾病所致,急 性,感染性心内膜炎 创伤 主动脉夹层 人工瓣膜撕裂,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,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,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,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,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,Chronic AI Clinical Manifestation: Peripheral Signs,实验试剂600元,Peripheral Signs,Duroziezs sign,femoral retrograde bruits,Traubes sign,pistol shot femorals,De Mussets sign,systolic head bobbing,周围血管征常见：点头征、枪击音、双期杂音,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,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,Aortic Incompetence : Laboratory Examination,X-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,Aortic Incompetence Laboratory Examination,X-ray,Aortic incompetence with massive diffuse aortic dilation (companied with Left atrial & ventricular enlargement),Aortic Incompetence Laboratory Examination,Left ventricular hypertrophy with prominent positive anterior T waves has been described with “diastolic overload” syndrome,ECG,Aortic Incompetence Laboratory Examination,Echo have decisive effort in diagnosis of AI,Echocardiography,Aortic Incompetence Diagnosis & Differential Diagnosis,S1A2 Cardiac base region SM Austin-Flint murmurs Precordial Palpable S3 SBP，DBP，pulse pressure Dilatation of aorta LA & 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,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 Murmur,Pulmonary incompetence results from Severe pulmonary artery hypertension,Differential Diagnosis,Aortic Incompeten