心脏瓣膜病valvular heart disease （200p）课件

ValvularHeartDisease RonaldD Agostino D O F A C C F A C P DirectorofNon InvasiveCardiologyLongIslandCardiovascularandInternalMedicineManhasset N Y CalcifiedAoValve2ndtoacquiredAoVStenosis Severelycalcifiedtricuspidvalvefromanelderlypatient Phonogramofa20yoawomenwithmoderateAoVcongenitalstenosiswithabicuspidvalve presentingwithanejectionclick increasedA2andsystolicejectionmurmur Phonogramofa20yoamalewithseverenon calcifiedAoVS SeenhereisaparadoxicalsplittingofS2 latesystolicejectionmurmurandprominentS4 TheLVisnotedtohavealowvolumeandaslowupswingofthecarotidpulse ApexcardiogramofthesevereAoVSshowingasustained a wave causingapalpableS4gallop thenon compliantventricle 70yoamalewithseverAoVS notetheabsenceofboththeejectionclickandAosecondsound circled Alsothereisaslowupswingofthecarotidpulse Thewindowtotheinnerworld TheEyesNotethemultiplecalcificemboliintheretinaofthiselderlypatientpresentingwithamaurosisfugaxPatientwasDxwithsevereacquiredAoVS CathetergradientsarereportedaspeaktopeakpressuredifferencesThisisnotatruemeasurementofpressuredropoffacrosstheAoVbecausetheydonotoccuratthesametimeEchocardiogramisidealforpressuredropoffacrossthevalveThetwoshouldbeusedtogethertoevaluatethepatientforvalidationstudiesPeaktoPeakpressurediffPressureDropoff PercutanousvalvuloplastywithaprophylacticRVPacemakertocombatbradycardiaduringtheprocedure RossProcedure Survivalintheelderly aveageof60 afteraAoVreplacement AVR PtwithMarfan ssyndrome Marfan swithtype AAodissection Growththeheartmuscle A Infant sheartweighingabout15gmandLVis7gmB Adult sweighing300gmand100gmrespectivelyC Athlete sis500gmsand200gmD ConcentricHypertrophy 650gmsand400gmsE DecompensatedEccentricHypertrophy 900gmsand500gms fewermyocytesarenoted replacedbyfibroticscartissue rh PulseandReflectedwavevelocitiesinanelasticAo Whataboutinastiffaorta PreandPostopCXRofapatientwithAoVRegurgitationNotethedecreaseinlongandshortdiametersfromtheStarr Edwardsvalvereplacementprocedure TypicalLVHassociatedwithAoVRwithastrainpatternandtallT waves LVwallstresscanbereducedwithACE Iorhydralazines butonlyACE IarenotedtodecreaseLVmassindexandimproveEF smoreeffectively SurvivalRates Patientwithovertpulmonaryedema Notethecharacteristic batwingsign ontheCXR fluiddistribution Top myxomatousMVBottom NlMV PhonogramofsevereFMVandMVR EchoofanFMPwithMVPindiastole NotetheMVprolapsingintotheLA LVcineangiographyintheRAOandLAOprojection LVVentriculogramofaptwithMR It snotjusttheheart S SofFMV MPVisadynamicinter relationshipbetweentheCardiac NeuroendocrineandAutonomicNervousSystem PhonogramwithsimultaneousECGofaptpostMVrepair notetheabsenceofamurmur pre opbelow Quick what sthisECGshowing B SSingleTiltingDisk M HSingleTiltingDisk ContainsaTeflonsewingring titaniumhousingandcarboncoateddisks St JudeBi leafletTiltingDisk C EStentedporcineBioprosthesis HancockIIStentedBioprosthesis C EStentedPericardialBioprosthesis TorontoStentlessPorcineValve AusculatoryFindingWithProstheticValves TheSt JudeHeartValvehasregurgitantflowthatisperpendiculartothevalveRegurgitationisnotedatthediskmarginsandtheextremesoftheclosureline Prostheticvalvesarepronetoperforate TEEofanendocarditisoriginatingfromtheprostheticvalve AnotherView AnyoneknowwhatDressler ssyndromeis VegetationsonaMV2ndtoInfectiveEndocarditisfromH Flu Strep Sanguis oranypathogen cancauseocclusivecoronaryembolizationofthecoronaryostium Subungualhemorrhages splinterhemorrhages areindicativeofAcuteinfectiveendocarditis Ifyouseeneedletracks thinkinfectiveendocarditis tricuspidperforationiscommonwithIVDA Doeseverybodyseethevegetationontheposteriorleaflet inthispatientwithsevereMVP HMO sTwodoctorsandanHMOmanagerdiedandlinedupatthePearlyGatesforadmissiontoHeaven St Peteraskedthemtoidentifythemselves Onedoctorsteppedforwardandsaid Iwasapediatricspinesurgeonandhelpedkidsovercometheirdeformities St Petersaid Youcanenter Theseconddoctorsaid Iwasapsychiatrist Ihelpedpeoplerehabilitatethemselves St Peteralsoinvitedhimin Thethirdapplicantsteppedforwardandsaid IwasanHMOmanagerandIhelpedpeoplegetcost effectivehealthcare St Petersaid Youcancomeintoo AstheHMOmanagerwalkedby St Peterquietlyadded Butyoucanonlystaythreedays Afterthatyoucangotohell ValveSurgery AorticStenosis Indicationsforsurgery HemodynamicallysevereASwithorwithoutsymptomsHighriskofsuddendeathimmediatesurgeryindicatedHemodynamicallymildtomoderateASwithsymptoms1 3willdiewithin4yearsPromptsurgeryindicated IndicationsforSurgeryforSevereAorticStenosis AllSymptomaticPatients NormalLV ASAPLVDysfunction UrgentHeartFailure Emergent AsymptomaticPatients AllpatientswithAVA 0 75cm2AllpatientswithAVA0 76 1 0cm2PainlessIschemiaSignificantarrhythmiasSevereLVHLVdysfunction AorticInsufficiency Latentperiodtocardiacdecompensation OncedeteriorationbeginsLVfailsrapidlySuddendeathisnotcommonSymptoms promptsurgeryNosymptoms followcloselyfordecreasedLVfunction AorticValveSurgery Repair Notoftendone Nolongtermresults ReplacementisprocedureofchoiceReplacement ProcedureofchoiceMechanicalValveTissueValve ChoosingaValve Idealartificalvalvewould BeeasytoimplantLastforeverAllowbloodtofloweasilythrucentralopening preventreverseflowwhenclosedBemadefrommaterialthatwouldnotdamagecellsorpromotebloodclotformationBeeasytoobtain SelectingaValve Whenselectingareplacementvalvethesurgeonmust Weightheadvantages disadvantagesofeachvalvetype Knowpatient slifestyle age size medicalhistory abilitytotolerateanticoagulation CagedBallValve Starr Edwards MetalballcagewithstrutsmountedonringInsidecageishollowmetalorplasticball poppet Theforwardmotionofbloodforcesthepoppetintothecage Bloodflowsthruthecage aroundpoppet Ball Cage Advantages Durability Disadvantages PronetoclotformationBloodflowthru aroundpoppetcancauseclotstobreakfree enterbloodstreamRequireslong termanticoagulation TiltingDiscValve MadeofpyrolyticcarbonMobilelens shapeddiscattachedtocirularringby2transversestruts Disctiltsopen60 80degreesallowingbloodtoflowaroundthedisc TiltingDisc Advantages DurabilityLessbloodflowobstructionthancaged ball Disadvantages PronetoclotformationLongtermanticoagulationrequired Bi LeafletValve NewestmechanicalvalveMostcommonvalveinUSA2pivotingsemicirculardiscsmounteddirectlytosewingring DiscsopenperpendicularlyBloodflowsthruring arounddiscsWhenclosedthediscslieflat preventingregurgitantbloodflow Bi LeafletValve Advantages DurabilityApproximatesnormalvalvefunction Disadvantages Pronetoclotformation lessthanothermechanicalvalves Requireslongtermanticoagulation TissueValves PorcineXenograft Aorticvalveofpig harvestedintact preserved mountedonsewingring Wheninplace bloodflowsalmostunobstructedthrucentralopening PorcineXenograft Advantages Noanticoagulationrequired Disadvantages LimiteddurabilityIncreasedfailureafter5 7years PericardialXenograft Obtainedfromcalfpericardium 3leafletsformedfrompreservedpericardium mountedonDacronframe Bloodflowisvirtuallyunobstructed Advantages disadvantagessameasporcinexenograft Homograft FrozenAVofhumancadaver Harvestedvalveisthawed trimmed sewnintoplace Nomountingmaterialisneeded Homograft Advantages ExcellenthemodynamicsLittleriskofclotformationRareneedforanticoagulation Disadvantages DifficulttoobtainLimiteddurabilityOnlyforAVR PulmonaryAutograft RossProcedure Subtitutionofpatient spulmonaryvalvefortheaorticvalve Onlyreplacementthatistrulyalive potentiallyabletolastanormallifetimewithoutbloodthinnersHasbeenshowntogrowwiththerestofthebodyinyoungchildren AVR MedianSternotomyCPBValveexposure inspectionofvalve rootsurroundingtodetermineextentofdiseaseValveissizedChosenvalveissewnintoplaceWeanfromCPB StepsinAorticValveReplacement RiskFactorsforSurvivalAfterAVR IncreasedageDecreasedLVfunctionCADEndocarditisMismatchofprosthesis bodysizeNYHAFunctionalstatusAscendingAorticAneurysm MitralStenosis Indicationsforsurgery SurgerynotusuallyrecommendedinasymptomaticpatientsPatientswithfewsymptomsthatareotherwisehealthyshouldhavesurgeryPatientswithsevereMSshouldhavesurgery MitralInsufficiency IndicationsforsurgeryaremorecomplexthanforMitralStenosisPatientswithMRbecomesymptomaticonlyafterLVfunctionhasbeenseverely irreversiblydamaged atwhichtimesurgicalresultsaremuchlessfavorable MitralValveRepair Abletoperformrepairwhen Prominentopeningsnap novalvecalcificationPliableleaflets commissuralfusionNormalchordae papillarymuscle ClosedCommissurotomy FirstmitralvalvesurgerytobeperformedFirstperformed1923 suggestedasearlyas1898Rarelyperformedtoday OperativeTechnique LeftAntero lateralthoracotomyPericardialsacopenedlongitudinallySuture tourniquetplaced baseofleftatrialappendagewhichisclamped opened Surgeon sindexfingerisintoducedthruopening clampremovedsothattheLA MVcanbedigitallyexplored TransventriculardilatorintroducedthrusmallincisioninLV ClosedMitralCommissurotomy Advantages SimpleRapidCost effectiveLowlikelihoodofendinginvalvereplacement Disadvantages RestenosisratevariesgreatlyNot exactscience LimiteduseHighriskofintra opembolism OpenCommissurotomy MedianSternotomy CPBWideatrialincisionmade valveexposedAnnulus leaflets commissures chords papillarymusclesexamined analyzedMVobservedthruopenatriumasventricleisfilledunderpressureDecisionthenmaderegardingreconstructionorvalvereplacement MitralValveSurgery OpenCommissurotomy Advantages RelativelysafePreferredtovalvereplacement Disadvantages MedianSternotomyCPB RingAnnuloplasty Theroleoftheringannuloplastyisto Correct preventfurtherannulardilatationIncreaseleafletcoaptationReinforceannulusfollowingrepairKeeptensionofffragilesuturelines scaffolding Restorethesize shapeofvalveorifice VALVEANNULOPLASTY Valvuloplasty UsedtorelievevalvularstenosisinselectedpatientsLocalanesthesia mildsedationBalloonpassedthrunarrowedvalve inflated Provideslong termimprovementinpatientswithMS LimitedreliefinAS IndicationsforValveReplacement EndocarditisAcuteIschemicMitralRegurgeRheumaticHeartDiseaseDegenerationofvalve MitralValveReplacement ChestWallIncisions MedianSternotomy mostcommon Rightthoracotomy isolatedforre opMVR Leftthoracotomy rarelyused MitralValveReplacement MedianSternotomy mostcommonincision CPBMitralvalveexposed examinedtodeterminehowmuchtissuetoremove PreservationofchordaetendonaeValveissizedusingsizingtoolNewvalveissewnintoplace suturelineinspected CPBweaned chestclosed ChordalPreservation EvidencesuggeststhatpreservationofChordae posteriorleafletofMVisimportantinmaintainingthenormalLVfunctionCompleteexcisionisnecessaryin EndocarditiswithinfectedtissueHeavilycalcifiedvalvularapparatus MVRFacts MVRhashighermortalitythanAVR2mostimportantfactorsareLVfunction ageValvesinmitralpositiondegeneratefasterthanaorticortricuspid Tricuspid MitralValves Thetricuspidandmitralvalvesfunctionasaunitbecausetheatrium fibrousrings valvulartissue chordaetendonae papillarymuscleandventricularwallsareconnected Damagetoanyoneofthese6partscanaltertheheart sfunctionsignificantly ValveStructure CausesofValvularDisease DegenerativeDiseaseRheumaticHeartDiseaseInfectiveEndocarditisComplicationofAcuteMI ValveAreas NORMALVALUESAorticValve 2 5 3 5cm2MitralValve 4 6cm2TricuspidValve 4 6cm2 MVNarrows LAPIncreases LADilates PulmonaryVascularPressureIncrreases RVEnlargementRAEnlargement PathophysiologyofMitralStenosis Dyspnea PulmonaryEdema RVFailure JVD LiverEngorgement Ascites PeripheralEdema ClinicalFindingsinMitralStenosis AtrialDysrrhythmiasDiastolicMurmurSymptomsstartwhenValvearea 1 5cm2 IncreasedRAP PAP PAWPDecreasedCO CIFatigue Dyspnea JVDHoarseness Dysphagia RupturedPapillaryMuscle ClinicalF