valvularlesionsweb课件.ppt

ValvularLesionsoftheHeart Allphotosretainthecopyrightsoftheiroriginalowners 2005WilliamHerring MD Toadvanceslide usespacebar useleftarrowforpreviousslide usebrowser sbackbuttontoexitprogram AorticStenosis AorticStenosisFrequencyofCauses 1 Degenerationofbicuspidaorticvalve2 Degenerationoftricuspidaorticvalveinperson 65yearsold3 Rheumaticheartdiseaseinatricuspidvalve AorticStenosisLocations SupravalvularValvularSubvalvular SupravalvularAorticStenosis SupravalvularAorticStenosisGeneral UncommonTypesHourglassMembraneHypoplasiaofentireascendingaortaAssociatedlesionsin William ssyndrome SupravalvularAorticStenosis William ssyndromeSupravalvularAostenosisHypercalcemiaElfinfaciesPulmonarystenosesHypoplasiaofaortaStenosesinRenals celiac SMA ValvularAorticStenosisCongenital CongenitalValvularAorticStenosisGeneral Bicuspidaorticvalveisthemostcommoncongenitalcardiacanomaly0 5 2 UsuallynotstenoticduringinfancyMorepronetofibrosisandcalcificationthannormalvalve Manymalformationsofaortaand orLVareassociatedwithbicuspidvalveIn50 ofcoarctationofaortaHypoplasticleftheartsyndromeInterruptionofaorticarch CongenitalValvularAorticStenosisAssociations CongenitalValvularAorticStenosisCalcification BicuspidvalvesaremostapttocalcifyCalcificationbeginsearlier 4thdecade thanindegeneratedtricuspidAovalve 65 EarlycalcificationcanalsooccurwithRheumaticheartdz CalcificationofAorticValve Calcificationoftheaorticvalvecanreallyonlybeseenonalateralchestx ray CongenitalValvularAorticStenosisAngiographicfindings Anon calcified bicuspidvalverevealsthickeninganddomingofvalveleafletsinsystoleAjetofnon opacifiedbloodisvisiblethroughstenoticbicuspidvalveThisjetdoesnotoccurwithacquiredAS Unopacifiedjetstreamthroughabicuspidaorticvalve Acquiredaorticstenosiswouldnotdemonstratethisjetbecauseseveredeformityofvalve turbulentflow Leafletsare domed onsystole CongenitalValvularAorticStenosisAngiographicfindings Congenitallybicuspidvalvesusuallyhave2aorticsinuses3sinusesinacquiredASInrheumaticdisease aorticvalvecommissuresusuallyfuseDon tfuseindegeneratedtricuspidvalve FrankNetter MDNovartis ValvularAorticStenosisAcquired AcquiredValvularAorticStenosisCauses Fusion thickeningorcalcificationofatricuspidaorticvalveDegenerativeprocess 65yearsold Rheumaticheartdisease younger ValvularAorticStenosisDifferentiatingFeatures AorticStenosisX RayFindings Dependsonagepatient severityofdiseaseIninfants AS CHF pulmonaryedemaInadultsNormalheartsizeUntilcardiacmuscledecompensatesEnlargedascendingaorta2 post stenoticdilatation2 turbulentflowNormalpulmonaryvasculature Aorticstenosis Prominenceofascendingaortafrompost stenoticdilatation Normal sizedheart Post stenoticDilatationofAorta FromturbulentflowjustdistaltoanyhemodynamicallysignificantarterialstenosisJeteffectalsoplaysroleOccursmostlywithvalvularaorticstenosisMayoccuratanyage Aorticstenosis Prominenceofascendingaortafrompost stenoticdilatation AorticStenosisCalcificationofValve Infemales calcificationusuallyindicateshemodynamicallysignificantASCalcificationofvalveusuallyindicatesgradientacrossvalveof 50mmHgSeenbestonlateralviewonchestx ray SubvalvularAorticStenosis SubvalvularAorticStenosisSubaorticStenosis AssociatedwithHypoplasticleftheartsyndromeIdiopathicHypertrophicSubaorticStenosisSubaorticfibrousmembrane SubaorticFibrousMembrane Aorticvalve About15 ofpatientswithcongenitalobstructiontoLVOFMembranejustbelowaorticvalveMayattachtoanteriorleafletofmitralvalveMitralregurgAorticregurg Ao FrankNetter MDNovartis Chestpain AorticStenosisClinicalTriad AorticRegurgitation AorticInsufficiency AorticRegurgitationCauses RheumaticheartdiseaseMarfan sLueticaortitisEhlers DanlossyndromeEndocarditisAorticdissection ThickenedcuspsMayhavecommissuralfusionIndegenerativeAoregurg nocommissuralfusionRegurgitantjetisusuallycentralIndegenerative usuallynotdiscretejet AorticRegurgitationRheumaticHeartDisease AorticRegurgitation2 RheumaticDz Thickeningofthecusps Commissuralfusion FrankNetter MDNovartis AorticRegurgitationImagingFindings X rayhallmarksLeftventricularenlargementEnlargementofentireaortaCineMRI gradientrefocusedMRI Whiteblood techniqueSignallosscomingfromAovalveintoLVduringdiastoleColorDopplerisalsodiagnostic AorticRegurgitationCineMRimageduringdiastoleshowssignalvoidemanatingfromtheaorticvalve LV Ao RA AorticRegurgitation Enlargedleftventricle Enlargementofentireaorta MitralStenosisLeftAtrialOutflowObstruction MitralStenosisRheumaticValvularHeartDisease Rheumaticheartdiseasecausesmitralstenosisin99 8 ofcases AcuteRheumaticValvulitisPathophysiology MultipleepisodesofAcuteRheumaticFever ARF first pancarditis FrankNetter MDNovartis AcutephasesubsidesFibrosisaltersleafletandcuspstructureResultsinleafletorcuspalthickeningalongvalvularmarginsofclosureValvesaffectedMostoftenmitralvalvealoneThenmostoftenmitralandaortictogetherLastlyaorticalone AcuteRheumaticValvulitisPathophysiology Normalmitralvalve Stenoticmitralvalve Fusionofchordae Thickeningofcusps ChronicMitralStenosisPathophysiology Mitralorificebecomessmallerleadingto TwocirculatorychangesLeftatrialpressure tomaintainLVfillingacrossstenoticvalveOverall bloodflowacrossmitralvalveis whichleadsto cardiacoutput EffectsofMitralStenosis OnheartOnlungsOnrightventricle EffectofMitralStenosisOnHeart Leftatriumhypertrophiesanddilates2 pressureAtrialfibrillationandmuralthrombosisfollowLeftventricleis protected bystenoticmitralvalveLVusuallynormalinsizeandcontour EffectofMitralStenosisOnHeart Pulmonaryarterialpressure Intimalandmedialhypertrophyofpulmonaryarteries pulmonaryvascularresistanceRightventricledilatesfrompressureoverloadMainpulmonaryarterydilates pulmonaryvalveregurgitation EffectofMitralStenosisOnHeart Tricuspidregurgitationdevelops2 dilatedRVRightatriumdilates2 volumeoverloadRightheartfailure MitralstenosisoccursLeftatrialpressure LeftatriumenlargesCephalizationPIEPAHdevelopsPVRincreasesRVenlargesPulmonicregurgdevelopsTricuspidannulusdilatesTricuspidinsufficiencyRVfailure TimecourseofMSinadult FrankNetter MDNovartis PulmonaryarterialhypertensiondevelopsFirstpassivelyThen2 muscularhypertrophyandhyperplasia increasedpulmonaryvascularresistance EffectofMitralStenosisOnLungs Chronicedemaofalveolarwalls fibrosisPulmonaryhemosiderindepositedinlungsPulmonaryossificationmayoccur EffectofMitralStenosisOnLungs EffectofMitralStenosisonLungsNormalchamberpressures M1 5 M5 10 D1 7S17 32M15 D5 12S90 140 Pulmonaryvenousandcapillarypressure EffectofMitralStenosisOnLungs RVhypertrophiesinresponsetoincreasedafterloadEventuallyRVfailsanddilatesCausesdilationoftricuspidannulus tricuspidregurgitation EffectofMitralStenosisOnRightVentricle RightVentricularHypertrophy Stenoticmitralvalve FrankNetter MDNovartis X RayFindingsofMSCardiacFindings UsuallynormalorslightlyenlargedheartEnlargedatriadonotproducecardiacenlargement onlyenlargedventriclesStraighteningofleftheartborderOr convexityalongleftheartborder2 toenlargedatrialappendageOnlyinrheumaticheartdisease MitralStenosis Straightening ofleftheartborder Normal sizedheart MitralStenosis Convexityfromenlargedleftatrialappendage MitralStenosis Convexityfromenlargedleftatrialappendage X RayFindingsofMSCardiacFindings SmallaorticknobfromdecreasedcardiacoutputDoubledensityofleftatrialenlargementRarely rightatrialenlargementfromtricuspidinsufficiency RA LA Smallaortafrom cardiacoutput Doubledensity Mitralstenosis regurgitationwithtricuspidregurgitation Rightatrialenlargementfromtricuspidregurgitation EnlargedLatrialappendagefrommitralstenosis X RayFindingsofMSCalcifications Calcificationofvalve notannulus seenbestonlateralfilmandatangioRarely calcificationofleftatrialwall2 fibrosisfromlong standingdiseaseRarely calcificationofpulmonaryarteriesfromPAH Calcificationofmitralvalve Calcificationofpulmonaryartery2 long standingPAH Calcificationofleftatrialwall Ao Mitral X RayFindingsofMSPulmonaryFindings CephalizationElevationofleftmainstembronchus especiallyif90 totrachea Enlargementofmainpulmonaryartery2 pulmonaryarterialhypertensionSevere chronicdiseaseMultiplesmallhemorrhagesinlungPulmonaryhemosiderosis Upperlobevesselsequaltoorlargerthansizeoflowerlobevessels Cephalization Elevationofleftmainstembronchus2 LA Posteriorviewofheart FrankNetter MDNovartis EnlargedMPAsegmentfromseverepulmonaryarterialhypertension Straighteningofleftheartborderfrom LA MitralStenosiswithseverePAH MitralValveCalcification PresenceindicatesMSCalciumusuallydepositedinclumpsonvalveleafletsHeaviercalcificdepositsinmenthanwomen FrankNetter MDNovartis MitralAnnulusCalcification CalcificationofmitralannulusdoesnotsignifypresenceofmitralvalvediseaseOccursinolderwomenUsuallyasymptomaticRarely MitralStenosis MitralStenosisOtherCauses CongenitalmitralstenosisInfectiveendocarditisCarcinoidsyndromeFabray sDiseaseHurler ssyndromeWhipple sDiseaseLeftatrialmyxoma MS2 rheumaticdisease99 8 ofcases MitralStenosisCineMRimageinaxialplanedemonstratesadiastolicsignalvoidemanatingfromthemitralvalve LA LV RA RV CongenitalMitralStenosis Existsasisolatedabnormality25 oftimeCoexistswithVSD30 oftimeCoexistswithanotherformofleftventricularoutflowobstruction40 oftime SHONE SSyndrome Shone sSyndrome ParachutemitralvalveSupravalvularmitralringSubaorticstenosisCoarctationofaorta LAMyxoma Mostcommonformof1 cardiactumor86 ofmyxomasfoundinleftatrium90 ofmyxomasaresolitaryUsuallyoccuraroundfossaovalisSofttissue notfat density LeftAtrialMyxomaContrast enhancedCTshowslargefillingdefectinlumenofLA LeftAtrialMyxomaCineMRIshowssofttissuemassarisingfromwallofleftatriumandprojectingintolumen LA RA LV Ao Leftatrialmyxoma FrankNetter MDNovartis MSandMR RheumaticmitralstenosisoccurswithvaryingdegreesofmitralregurgitationWhenMSissevere MRisrelativelyunimportant MitralRegurgitation MitralRegurgitationCauses Thickeningofvalveleaflets2 rheumaticdiseaseRuptureofthechordaePosteriorleafletmoreoften Trauma Marfan sPapillarymuscleruptureordysfunctionAcutemyocardialinfarctionLVenlargement dilatationofmitralannulusAnycauseofLVenlargementLVaneurysm valvulardysfunctionAcutemyocardialinfarction MitralRegurgitationGeneral Theacutelesionofrheumaticfeverismitralregurgitation notstenosisThelargestleftatriaeverareproducedbymitralregurgitation notmitralstenosis MitralRegurgitationX rayFindings InacuteMRPulmonaryedemaHeartisnotenlargedInchronicMRLAandLVaremarkedlyenlargedVolumeoverloadPulmonaryvasculatureisusuallynormalLAvolumebutnotpressureiselevated Mitralregurgitation Markedlyenlargedheart LargeLeftatrium Normalpulmonaryvasculature Mitralregurgitation Mitralregurgitation MitralRegurgitationCineMRimageinaxialplaneduringsystoledepictsasignalvoidemanatingfromthemitralvalve LA LV MitralStenosis MitralRegurgitation Differenceinheartsize MSandMR PulmonicStenosis PulmonicStenosisGeneral WithoutVSD 8 ofallCHDMostlyasymptomaticWhensymptomaticCyanosisandheartfailureCorpulmonaleLoudsystolicejectionmurmur PulmonicStenosisTypes SupravalvularValvularSubvalvular SupravalvularPulmonicStenosisGeneral Maybeeithertubularhypoplasiaorlocalizedwithpost stenoticdilatation SupravalvularPulmonicStenosisAssociatedCVabnormalities ValvularpulmonarystenosisSupravalvularaorticstenosisVSD PDASystemicarterialstenoses SupravalvularPulmonicStenosisAssociatedSyndromes WilliamsSyndromeHypercalcemiaPulmonicStenosisSupravalvularASPeculiarfaciesPost rubellasyndromeCarcinoidsyndromewithlivermetsEhlers Danlossyndrome ValvularPulmonicStenosisGener