心脏瓣膜病.ppt

ValvularHeartDisease,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。,Mitralvalvedisease,二尖瓣疾病,Mitralstenosis(MS),二尖瓣狭窄,EtiologyandPathology（病因和病理）,Rheumaticheartdisease(风湿性心脏病)Congenitalmalformation(先天性畸形)Senilemitralannulusandsubvalvularcalcification(老年人二尖瓣环及环下区钙化),Pathophysiology(病理生理),Thecross-sectionalareaofthemitralvalveorifice(瓣环口面积）Normaladults4-6cmMildMS2cmModerateMS1.5cmSevereMS1.0cm,TheeffectonLAandcardiacoutputofMSMildMS：LA压力轻度升高，心排血量正常SevereMS：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Theeffectonthepulmonarycirculationandrespirationofelevatedleftatriumpressure,LAPVP、PCPlungcongestion/pulmonaryedemapulmonaryarteryintimahyperplasiaandthickening（肺动脉内膜增生肥厚）PAP（肺动脉压升高）Rightheartfailure（右心衰竭）,Remarks(备注),PAP：肺动脉压PCP：肺毛细血管压PVP肺静脉压,Clinicalsituation(临床表现),一、Symptom(中度狭窄始出现症状)Exertiondyspnea(劳力性呼吸困难)Hemoptysis(咯血)支气管静脉压破裂出血肺梗死肺水肿,Hoarseness（声嘶）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N,Clinicalsituation,二、PhysicalSign(体征)Mitralfacies(二尖瓣面容)S1，可闻及OS(开瓣音)CardiacapexDM(心尖区舒张期杂音），oftenaccompanyingdiastolicthrill(舒张震颤）RV，P2excessive(亢进)，RelativeSMofTI(相对性三尖瓣关闭不全收缩期杂音),Laboratoryexamination(实验室检查),XRay二尖瓣型心：左房右室大，主动脉结缩小，肺动脉扩张，肺淤血ECGP0.12s,RV1,电轴右偏，心房纤颤，粗f波Echocardiogram(超声心动图)：是确诊、定量MS的可靠方法,M型：二尖瓣前后叶同向运动二维：狭窄瓣膜形态结构，瓣口面积，房室大小连续多普勒：测定血流速度、跨瓣压差Cardiaccatheterization(心导管术)测定肺毛细血管压和左室压，确定跨瓣压差，明确狭窄程度,DiagnosisandDifferentialdiagnosis(诊断和鉴别),Diagnosis心尖区DMLA扩大及实验室检查可诊断，超声有确诊价值Differentialdiagnosis二尖瓣口血流增加AustinFlint杂音左房粘液瘤：随体位改变的DM,Complication（并发症）,一、Atrialfibrillation(心房纤颤)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、Acutepulmonaryedema(急性肺水肿)为重度MS最严重的并发症及致死原因三、Embolism(栓塞)80%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）,四、Rightheartfailure(右心衰竭)五、Pulmonaryinfection(肺部感染),Prognosis(预后),无症状者可存活多年，一旦有症状至致残平均7.4年死亡原因多为上述并发症,Therapy(治疗),Generaltherapy(一般治疗)：预防风湿热及感染性心内膜炎Hemoptysis(咯血)：减低肺静脉压力Atrialfibrillation：快速心室率时应用洋地黄Rightheartfailure：以利尿为主,Therapy(治疗),Acutepulmonaryedema：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Mechanictherapeutics(机械治疗)MS：经皮球囊二尖前瓣成型术；外科手术,Mitralincompetence:MI,二尖瓣关闭不全,EtiologyandPathology（病因病理）,Duringsystole,competence(关闭)ofmitralvalvedependontheintegrityofmitralstructureandfunction(includingleftletsofvalve,mitralannulus(瓣环),tendinouscords(腱索),papillarymuscle(乳头肌)andLV.EveryabnormalitymayleadtoMI.,一、ChronicMI,Rheumaticheartdisease:Theleftletsofmitralvalvefibrose,thicken,shortenandoftenaccompanyMSandaorticvalvediseaseMitralvalveprolapse(二尖瓣脱垂)CHD：Chronicischemia(缺血)orinfarction(梗死)leadtofibrosisandfunctionaldisorderofpapillarymuscle,一、ChronicMI,Calcificationofmitralringandsubvalvular(二尖瓣环及环下区钙化)InfectiveendocsrditisRuptureofchordaetendineae(unknowncause)LVenlargedsignificantly(左室显著扩大)Else,二、AcuteMI,Ruptureofchordaetendineae(腱索断裂)Endocarditisleadstotheleftletsofvalvedestruction(心内膜炎致瓣叶毁损)Acutemyocardialinfarction(急性心肌梗死)Traumaresultsinruptureofthemitralvalvecomponent(创伤使二尖瓣器破裂)Ruptureofprostheticvalve(人工瓣膜开裂),Pathophysiology,MILVEDVLVhypertrophyLVEDP,LALVfailurePulmonarycongestionPAPRightheartfailure,Clinicalsituation(临床表现),一、Symptom轻度MI可终身无症状，严重MI心排血量减少，感乏力、呼吸困难二、PhysicalSignHeavingapeximpulse(抬举性心尖搏动)Cardiacsound：S1（重度MI），S2分裂，闻及S3Cardiacmurmur：从S1后立即开始，与S2同时终止的SM，可伴收缩期震颤，向左腋、左肩胛下区传导；乳头肌功能不全、腱索断裂的杂音似海鸥鸣叫样,Laboratoryexamination,XRayECGEchocardiogram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,DiagnosisandDifferentialdiagnosis,心尖区SM心房、心室增大，诊断MI可成立，确诊有赖于超声心动图应与以下情况相鉴别：Tricuspidincompetence（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，RVVSD（室间隔缺损）,Systolicejectionmurmurinleftborderofsternum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,AtrialfibrillationInfectiveendocarditisEmbolismHeartfailure,Complication,Prognosis,急性严重返流者，若不及时手术，极难存活慢性MI无症状期长，一旦发生左心衰竭，预后不良,Therapy,Medicaltherapy(内科治疗)PreventendocarditisandrheumaticfeverPatientswhoareasymptomaticandhavingnormalcardiacfunctionneednttherapybutregularfollow-up(定期随访).Complicationarecuredinpatientswithcomplication.,SurgicaltreatmentProstheticvalvereplacement为主要手术方法，趋向早期手术有症状者应在LVEF0.5，平均肺动脉压20mmHg之前手术产生左室功能不全、LVEF0.30.5、年龄55岁、LVEDD80mm，已不置换瓣Valvuloplastyofmitralvalve(二尖瓣整复术)优点：不需长期抗凝，LV功能恢复较好,AorticValveDisease,主动脉瓣疾病,Aorticstenosis(AS),主动脉瓣狭窄,EtiologyandPathology,Rheumaticheartdisease：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Congenitalbicuspidvalve(先天性二叶瓣)Senilecalcific(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,Pathophysiology,Thecross-sectionalareaoftheaorticvalveorifice(瓣环口面积）Normaladult3.0cmThearea1.0cm,LVSP,transvalvepressuregradientmanifest(跨瓣压差明显),ASAfterloadingLVhypertrophyLVEDP,LAamplificationPAPPCPLungcongestionandedema,MyocardialischemiaMyocardialcontractilityHeartfailure,Clinicalsituation,SymptomASTriplesyndrom(AS三联症)Dyspnoea(呼吸困难):LungcongestionAngina(心绞痛)CausingbySynocope(晕厥)cardiacoutput,Clinicalsituation,PhysicalsignCardiacsound:S1isnormal,S2isparadoxicalsplitting(逆分裂),S4maybeheardCardiacmurmur:：SMisheardonthesecondintercostalspace(肋间)ofrightborderofsternum,andradiatetocervicalpart(颈部),leftinferiorborderofsternumandcardiacapexaccompanyingthrillCardiacdilatation(心脏扩大)，SBPandpulsepressuredecrease,Laboratoryexamination,X-Ray：心影可正常或稍大，晚期见肺淤血ECG：可有左室肥厚劳累征，及各种心律失常Echocardiogram：为确定、定量AS的重要方法Cardiaccatheterization：可根据左室-主动脉压差计算瓣口面积,DiagnosisandDifferentialdiagnosis,Diagnosis典型的收缩期杂音，易于诊断；多瓣膜病变提示风心病单纯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DifferentialdiagnosisAS应与左室流出道梗阻性疾病鉴别,Complication,Arrhythmia：10%可发生房颤、室性心律失常、房室传导阻滞，可至猝死、晕厥InfectiveendocarditisEmbolismHeartfailure：发生左心衰后，病情迅速恶化Gastrointestinalhemorrhage(胃肠道出血)：15-20%胃肠道血管发育不良,Prognosis,一旦出现症状，平均寿命仅三年。死亡原因为：左心衰、猝死人工瓣膜置换术后，远期存活率优于内科治疗,Medicinetherapy,Principalobjective：确定狭窄发生度、观察病情进展，争取手术机会择期手术Methods预防感染性心内膜炎、风湿热AS不能耐受房颤，一旦出现即时转复处理心衰,PBAP:Percutaneousballoonaorticvalvuloplasty(经皮球囊主动脉瓣成形术),适用于高龄患者、不宜换瓣及妊娠等情况，作为姑息治疗,Aorticincompetence,主动脉瓣关闭不全,Etiologyandpathology,一、ChronicAI（一）：AorticvalvediseaseRheumaticheartdisease:占2/3，由于瓣叶纤维化、增厚缩短，影响闭合，常合并AS及二尖瓣损害Infectiveendocarditis:为单纯AI的常见病因Congenitalmalformation:先天性二叶瓣、室间隔缺损伴一叶瓣脱垂、先天性主动脉瓣穿孔Aorticvalvemucinousdegeneration(主动脉瓣粘液样变性):可致主动脉瓣脱垂,Etiologyandpathology,（二）：Aortarootdilatation：瓣环扩大，瓣叶关闭不全Syphiliticaortitis(梅毒性主动脉炎)：主动脉炎致主动脉根部扩张,30%呈AIMarfarssyndrome：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SeverehypertensionoratherosclerosisIdiopathicdilatationofascendingaorta(特发性升主动脉扩张),Etiologyandpathology,二、AcuteAIInfectiveendocarditisTraumaDissectionofaorta(主动脉夹层分离):夹层血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、高血压或妊娠Ruptureofprostheticvalve(人工瓣膜破裂),Pathophysiology,ChronicaorticregurgitationLVEDVSBPofLVaftermanyyearsDBPofaortaanginaLVEDPPulsepressureLVdilatingandhypertrophyPeripheralvascularsignLAP、PVPLeftheartfailure,Remarks(备注),SBP：收缩压DBP：舒张压PVP：肺静脉压LAP：左房压LVEDP：左室舒张末压Peripheralvascularsign：周围血管征,Clinicalsituation,PhysicalSign:SP,DP,PP1.PeripheralvascularsignWater-hammerpulse(水冲脉)Pistolshotsound(枪击音)Demussetsigns(点头运动）Duroziezsigns(杜氏双重杂音)Capillarypulse(毛细血管搏动)Carotidarterypulse(颈动脉搏动),Clinicalsituation,PhysicalSign2.Apicalimplusedisplacedtoleftanddown(心尖搏动向左下移位)3.Cardiacsound：S1、S2减弱，可闻及S34.Cardiacmurmur：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。重度返流者，心尖区可闻及舒张早期隆隆样杂音（AustinFlint杂音）,Laboratoryexamination,X-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ECG：LV肥厚劳损Echocardiogram,DiagnosisandDifferentialdiagnosis,Diagnosis典型杂音周围血