Valvular-heart-disease瓣膜性心脏疾病课件

心脏瓣膜病TheFirstAffiliatedHospitalofGuangzhouMedicalUniversity

DepartmentofCardiovascular

Chenailan(陈爱兰)ValvularHeartDiseaseValvular-heart-disease瓣膜性心脏疾病Valvular-heart-disease瓣膜性心脏疾病Valvular-heart-disease瓣膜性心脏疾病RheumaticFeverDefinition:autoimmunediseasecausedbystreptococcalinfection,cross-reactbetweenstreptococcalantigensandstructuralglycoproteinofheart,joints,centralnervessystemandconnectivetissueValvular-heart-disease瓣膜性心脏疾病RheumaticHeartDiseaseInflammatoryprocessthatmayaffectthemyocardium,pericardiumandorendocardiumUsuallyresultsindistortionandscarringofthevalvesValvular-heart-disease瓣膜性心脏疾病RheumaticHeartDisease,cont.SubjectivesymptomsPriorhistoryofrheumaticfeverGeneralmalaisePain–mayormaynotbepresentObjectivesymptomsTemperatureMurmursDyspneapolyarthritisValvular-heart-disease瓣膜性心脏疾病RheumaticHeartDiseaseDiagnosisH/PWBCandESRC-reactiveproteinCardiacenzymesEKGChestx-rayEchoCardiaccathCardiacoutputValvular-heart-disease瓣膜性心脏疾病RheumaticHeartDiseaseNursingCareVitalsignsRestandquietenvironmentGiveantibiotics,digitalis,anddiureticsProvideadequatenutritionMonitorISOExplaintreatmentandhomecareValvular-heart-disease瓣膜性心脏疾病WhatAretheTypesofValveDisease?Thereareseveraltypesofvalvularheartdisease,include:1)Valvularstenosis:Whenavalveopeningissmallerthannormal2)ValvularInsufficiency/REGURGITATION:occurswhenavalvedoesnotclosetightly,thusallowingbloodtoleakbackwards.Bothvalvulardiseasescaninvolveallfourvalves.Valvular-heart-disease瓣膜性心脏疾病TypesMitralStenosisMitralRegurgitationMitralValveProlapseAorticStenosisAorticregurgitationTricuspidvalveisaffectedinfrequentlyTricuspidstenosis–causesRtHFTricuspidregurgitation–causesvenousoverloadValvular-heart-disease瓣膜性心脏疾病MitralStenosisValvular-heart-disease瓣膜性心脏疾病A75yearoldwomanwithloudfirstheartsoundandmid-diastolicmurmurChronicdyspneaClassII/VIFatigueRecentorthopnea(端坐呼吸)Nocturnalpalpitation&PND（夜间阵发性呼吸困难）PedaledemaValvular-heart-disease瓣膜性心脏疾病MitralStenosis:EtiologyPrimarilyaresultofrheumaticfeverScarring&fusionofvalve

apparatus&Degenerative(calcification)RarelycongenitalPureorpredominantMSoccursinapproximately40%ofallpatientswithrheumaticheartdiseaseTwo-thirdsofallpatientswithMSarefemale.Valvular-heart-disease瓣膜性心脏疾病MitralStenosis:PathophysiologyNormalvalvearea:4-6cm2Mildmitralstenosis:MVA1.5-2.5cm2MinimalsymptomsModmitralstenosisMVA1.0-1.5cm2usuallydoesnotproducesymptomsatrestSeveremitralstenosisMVA<1.0cm2Valvular-heart-disease瓣膜性心脏疾病MS→进入左室的血流受阻→LAP↑→PVP↑→左心衰甚至肺水肿→PAP↑长期重度肺动脉高压→右室扩大→右心衰MitralStenosis:PathophysiologyValvular-heart-disease瓣膜性心脏疾病Usuallytherearenosymptomsuntilthevalveorificeismoderatelystenosed(i.e.hasanareaof1.5cm2).Becauseofpulmonaryvenoushypertensionandrecurrentbronchitis,progressivelyseveredyspnoeadevelops.Acoughproductiveofblood-tinged,frothysputumandoccasionallyfrankhaemoptysismayoccur.Rightheartfailureanditssymptomsofweakness,fatigueandabdominalorlowerlimboedema.Atrialfibrillation,givingrisetopalpitations.Atrialfibrillationmayresultinsystemicemboli.MitralStenosis:SymptomsValvular-heart-disease瓣膜性心脏疾病MitralStenosis:SymptomsFatiguePalpitationsCoughLeftsidedfailureOrthopneaPNDPalpitationhoarseness(ortner’ssyndrome)AfibSystemicembolismPulmonaryinfectionHemoptysisRightsidedfailureHepaticCongestionEdemaWorsenedbyconditionsthatcardiacoutput.Exertion,fever,anemia,tachycardia,Afib,intercourse,pregnancy,thyrotoxicosisValvular-heart-disease瓣膜性心脏疾病RecognizingMitralStenosisPalpation:SmallvolumepulseTappingapex-palpableS1+/-palpableopeningsnap(OS)RVliftPalpableS2ECG:LAE,AFIB,RVH,RADAuscultation:LoudS1-asloudasS2inaorticareaA2toOSintervalinverselyproportionaltoseverityDiastolicrumble:lengthproportionaltoseverityInsevereMSwithlowflow-S1,OS&rumblemaybeinaudibleValvular-heart-disease瓣膜性心脏疾病MitralStenosis:PhysicalExamFirstheartsound(S1)isaccentuatedandsnappingOpeningsnap(OS)afteraorticvalveclosureLowpitchdiastolicrumbleattheapexPre-systolicaccentuation(esp.ifinsinusrhythm)S1S2OSS1Valvular-heart-disease瓣膜性心脏疾病CommonMurmursandTimingSystolicMurmursAorticstenosisMitralinsufficiencyMitralvalveprolapseTricuspidinsufficiencyDiastolicMurmursAorticinsufficiencyMitralstenosisS1S2S1Valvular-heart-disease瓣膜性心脏疾病MitralStenosis

LaboratoryExamination

ECG:1)leftatrialenlargement:Pwave(II,V1)2)Af;3)rightventricularhypertrophyX-film:changeincardiacsilhouette,KerleyBlinesEchocardiography:M-modeTwo-dimensionalDopplerValvular-heart-disease瓣膜性心脏疾病MitralStenosis:EKGLAERVHPrematurecontractionsAtrialflutterand/orfibrillation

freq.inptswithmod-severeMSforseveralyearsAfibdevelopsin

30%to40%ofptsw/symptomsValvular-heart-disease瓣膜性心脏疾病A75yearoldwomanwithloudfirstheartsoundandmid-diastolicmurmerValvular-heart-disease瓣膜性心脏疾病MitralStenosisECGValvular-heart-disease瓣膜性心脏疾病Valvular-heart-disease瓣膜性心脏疾病MitralStenosisX-rayfilmValvular-heart-disease瓣膜性心脏疾病MitralStenosis:RoleofEchocardiographyDiagnosisofMitralStenosisAssessmentofhemodynamicseverity

meangradient,mitralvalvearea,pulmonaryarterypressureAssessmentofrightventricularsizeandfunction.AssessmentofvalvemorphologytodeterminesuitabilityforpercutaneousmitralballoonvalvuloplastyDiagnosisandassessmentofconcomitantvalvularlesionsReevaluationofpatientswithknownMSwithchangingsymptomsorsigns.F/Uofasymptomaticpatientswithmod-severeMSValvular-heart-disease瓣膜性心脏疾病Valvular-heart-disease瓣膜性心脏疾病Rheumaticmitralstenosis

Valvular-heart-disease瓣膜性心脏疾病M型见“城垛样”改变RheumaticmitralstenosisValvular-heart-disease瓣膜性心脏疾病MitralStenosis

Diagnosis&Differentialdiagnosis

-Diastolicrumblingmurmuratapex+X-film+ECG+Echo-relativeMS;Austin-Flintmurmur;leftatrialmyxoma;GrahamsteellmurmurValvular-heart-disease瓣膜性心脏疾病MitralStenosis:ComplicationsAtrialdysrrhythmiasSystemicembolization(10-25%)Riskofembolizationisrelatedto,age,presenceofatrialfibrillation,previousemboliceventsCongestiveheartfailurePulmonaryinfarcts(resultofsevereCHF)HemoptysisMassive:20torupturedbronchialveins(pulmHTN)Streaking/pinkfroth:pulmonaryedema,orinfectionEndocarditisPulmonaryinfectionsValvular-heart-disease瓣膜性心脏疾病MitralStenosis:NaturalHistoryProgressive,lifelongdisease,Usuallyslow&stableintheearlyyears.Progressiveaccelerationinthelateryears20-40yearlatencyfromrheumaticfevertosymptomonset.Additional10yearsbeforedisablingsymptomsValvular-heart-disease瓣膜性心脏疾病MitralStenosis:TherapyMedicalDiureticsforLHF/RHFDigitalis/Betablockers/CCB:RatecontrolinAFibAnticoagulation:InAFibEndocarditisprophylaxisValvular-heart-disease瓣膜性心脏疾病MitralStenosis:TherapyBalloonvalvuloplastyEffectivelongtermimprovementSurgicalMitralcommissurotomyMitralValveReplacementMechanicalBioprostheticValvular-heart-disease瓣膜性心脏疾病ValvularHeartDisease

MitralRegurgitationValvular-heart-disease瓣膜性心脏疾病MitralRegurgitationEtiologySymptomsPhysicalExamSeverityNaturalhistoryTimingofSurgeryValvular-heart-disease瓣膜性心脏疾病An80yearoldwomanwithincreasingdyspneaLongstandingheartmurmurIncreasingdyspnea&fatigueRecentERvisitDxCHFValvular-heart-disease瓣膜性心脏疾病MitralRegurgitation:

EtiologyValvular-leafletsMyxomatousMVDiseaseRheumaticEndocarditisCongenital-cleftsChordae腱索Fused/inflammatoryTorn/traumaDegenerativeIEAnnulusCalcification,IE(abcess)PapillaryMusclesCAD(Ischemia,Infarction,Rupture)HCMInfiltrativedisordersLVdilatation&functionalregurgitationTraumaValvular-heart-disease瓣膜性心脏疾病MREtiology:SurgicalseriesMVP（mitralvalveprolaspse）二尖瓣脱垂(20-70%)Ischemia(13-40%)RHD(3-40%)Infectiousendocarditis(10-12%)Valvular-heart-disease瓣膜性心脏疾病MRPathophysiologyChronicLVvolumeoverload-»compensatoryLVEinitiallymaintainingcardiacoutputDecompensation(increasedLVwalltension)-»CHFLVE–

»annulusdilation–

»increasedMRBackflow–

»LAE,Afib,PulmonaryHTNValvular-heart-disease瓣膜性心脏疾病MR

SymptomsSimilartoMSDyspnea,Orthopnea,PNDFatiguePulmonaryHTN,rightsidedfailureHemoptysisSystemicembolizationinAFibValvular-heart-disease瓣膜性心脏疾病RecognizingChronic

MitralRegurgitationPulse:

brisk,lowvolumeApex:hyperdynamiclaterallydisplacedpalpableS3+/-thrilllateparasternallift2toLAfillingS1softornormalS2widesplit(earlyA2)unlessLBBBMurmer-FixedMR:pansystolicloudestapextoaxillanopostextra-systolicaccentuationMurmer-DynamicMR(MVP)midsystolic+/-clickuprightS3/flowrumbleifsevereValvular-heart-disease瓣膜性心脏疾病RecognizingAcuteSevere

MitralRegurgitationAcuteseveredyspnea,CHF&hypotensionLVsizenormalLVmay/maynotbehyperdynamicLoudS1Systolicmurmurmay/maynotbepan-systolicInflow/rumbleS3present-maybeonlyabnormalityRVliftTTE/TEEfordiagnosisChordalorpapilllarymusclerupture/tearInfarctionwithpapillarymuscleischaemiaortearInfectiousendocarditiswithleafletperforationordisruptionorchordaltearFlailMVsegmentValvular-heart-disease瓣膜性心脏疾病ComparingASandMRSystolicMurmursAorticstenosisMitralinsufficiencyMitralvalveprolapseTricuspidinsufficiencyDiastolicMurmursAorticinsufficiencyMitralstenosisS1S2S1Valvular-heart-disease瓣膜性心脏疾病MitralRegurgitation

LaboratoryExamination:ECG:LAenlargement,Af,LVhypertrophyX-Film:chronic–cardiomegaly(LV,LA)acute–interstitialedema(KerleyB)Echocardiography:two-dimensional,Doppler,colorflowmappingAngiocardiography&MagneticresonanceimagingValvular-heart-disease瓣膜性心脏疾病MitralRegurgitationECGValvular-heart-disease瓣膜性心脏疾病MitralRegurgitationX-rayFilmValvular-heart-disease瓣膜性心脏疾病MREchocardiographyBaselineevaluationtoidentifyetiology,quantifyseverityofMRAssessandquantifyLVfunctionanddimensionsAnnualorsemi-annualsurveillanceofLVfunction,estimatedEFandLVESDinasymptomaticsevereMRToestablishcardiacstatusafterchangeinsymptomsBaselinestudypostMVRorrepairValvular-heart-disease瓣膜性心脏疾病MREchocardiographyEtiology:flailleaflets(chord/paprupture)thick(RHD)postmvtofleaflets(MVP)vegetations(IE)Severity:regurgitantvolume/fraction/orificeareaLVsystolicfunctionincreasedLV/LAsize,EFValvular-heart-disease瓣膜性心脏疾病MREcho/DopplerValvular-heart-disease瓣膜性心脏疾病MitralRegurgitation

Diagnosis:systolicmurmuratapex+LA↑,LV↑+EchoDifferentialDiagnosis:relativeMR,ventricularseptaldefect,tricuspidregurgitation,aorticstenosisValvular-heart-disease瓣膜性心脏疾病Complication:Atrialfibrillation;congestiveheartfailure;thromboembolism;infectiveendocarditisManagement:-Medicaltreatment-SurgicaltreatmentMitralRegurgitationValvular-heart-disease瓣膜性心脏疾病TreatmentMildmitralregurgitationintheabsenceofsymptomscanbemanagedconservativelybyfollowingthepatientwithserialechocardiograms.ProphylaxisagainstendocarditisisrequiredAnyevidenceofprogressivecardiacenlargementgenerallywarrantsearlysurgicalinterventionbyeithermitralvalverepairorreplacement.Inpatientswhoarenotconsideredappropriateforsurgicalintervention,managementusuallyinvolvestreatmentwithACEinhibitors,diureticsandpossiblyanticoagulants.

Valvular-heart-disease瓣膜性心脏疾病ValvularHeartDisease

AorticStenosisValvular-heart-disease瓣膜性心脏疾病AorticStenosisEtiologyPhysicalExaminationAssessingSeverityNaturalHistoryPrognosisTimingofSurgeryValvular-heart-disease瓣膜性心脏疾病CommonClinicalScenariosYoungerpeopleFunctionalmurmurvsMVPvsbicuspidAVOlderpeopleAorticsclerosisvsaorticstenosisValvular-heart-disease瓣膜性心脏疾病AorticStenosis-EtiologyYoungpatientthinkcongenitalBicuspid2%population3:1male:femaledistributionCo-existingcoarctation6%ofpatientsRarelyUnicuspidvalveSub-aorticstenosisDiscreteDiffuse(Tunnel)Middleagedpatient(4&5thdecades)thinkbicuspidorrheumaticdiseaseOldpatientthinkdegenerative(6,7,8thdecades)Valvular-heart-disease瓣膜性心脏疾病AorticStenosis:EtiologyCongenitalbicuspidvalveisthemostcommonabnormalityRheumaticheartdiseaseanddegenerationwithcalcificationarefoundaswell

NormalBicuspidAoV“Normal”geriatric calcificvalveValvular-heart-disease瓣膜性心脏疾病SeverityofStenosisNormalaorticvalvearea2.5-3.5cm2Mildstenosis1.5-2.5cm2Moderatestenosis1.0-1.5cm2Severestenosis<1.0cm2Onsetofsymptoms0.9cm2withCAD0.7cm2withoutCADValvular-heart-disease瓣膜性心脏疾病PathophysiologyObstructiontoLVOT→LVH→LAH→PVP↑→Pulmonaryedema;LVEF↓→ischemiaofperipheral、rain、heart-Valvular-heart-disease瓣膜性心脏疾病InnocentMurmursCommoninasymptomaticadultsCharacterizedbyGradeI–II@LSBSystolicejectionpattern

Normalintensity&splittingofsecondsound(S2)NootherabnormalsoundsormurmursNoevidenceofLVH,andno

withValsalva

S1S2Valvular-heart-disease瓣膜性心脏疾病CommonMurmursandTimingSystolicMurmursAorticstenosisMitralinsufficiencyMitralvalveprolapseTricuspidinsufficiencyDiastolicMurmursAorticinsufficiencyMitralstenosisS1S2S1Valvular-heart-disease瓣膜性心脏疾病AorticStenosis:Physical

FindingsS1S2S1S2Mild-Moderate SevereValvular-heart-disease瓣膜性心脏疾病An83yearoldmanwith

exertionaldyspneaPreviouslywellGradualonsetClassII/IVdyspneaOccasionallightheadednesswithexertionO/E:2/6ejectionmurmurValvular-heart-disease瓣膜性心脏疾病An83yearoldmanwith

exertionaldyspneaIstheresignificantvalvularheartdisease?Whichvalve?Isthevalveplayingaroleinhisdyspnea?HowdoyoudistinguishAVsclerosisfromstenosis?WhataretheclinicalsignsofsevereAS?Whattestsareappropriate?Whenissurgeryindicated?Valvular-heart-disease瓣膜性心脏疾病AorticStenosis:SymptomsCardinalSymptomsChestpain(angina)ReducedcoronaryflowreserveIncreaseddemand-highafterloadSyncope/Dizziness(exertionalpre-syncope)FixedcardiacoutputVasodepressorresponseDyspneaonexertion&restImpairedexercisetoleranceOthersignsofLVfailureDiastolic&systolicdysfunctionValvular-heart-disease瓣膜性心脏疾病AorticStenosis:Physical

FindingsIntensityDOESNOTpredictseverityPresenceofthrillDOESNOTpredictseverity“Diamond”shaped,harsh,systoliccrescendo-decrescendoDecreased,delay&prolongationofpulseamplitudeParadoxicalS2S4(withleftventricularhypertrophy)S3(withleftventricularfailure)Valvular-heart-disease瓣膜性心脏疾病AorticStenosisLaboratoryExamination:ECG;X-film;Echocardiography;AngiographyDiagnosis&DifferentialDiagnosis:-murmur+Echo-MI,TI,VSD-othermurmursofLVOTobstructionValvular-heart-disease瓣膜性心脏疾病An83yearoldmanwith

exertionaldyspneaValvular-heart-disease瓣膜性心脏疾病AorticStenosisX-rayFilmValvular-heart-disease瓣膜性心脏疾病EchocardiogramEtiologyValvegradientandareaLVHSystolicLVfunctionDiastolicLVfunctionLAsizeConcomitantregionalwallmotionabnormalitiesCoarctationassociatedwithbicuspidAVValvular-heart-disease瓣膜性心脏疾病EchocardiogramValvular-heart-disease瓣膜性心脏疾病AorticStenosis

Complications:Suddendeath,heartfailure,arrhythmia,infectiveendocarditis,systemicembolismManagement:-Medicaltreatment-SurgicaltreatmentValvular-heart-disease瓣膜性心脏疾病AorticStenosis:PrognosisSymptom/SignLiveexpectancyAngina5yearsSyncope2-3yearsCongestiveHeartFailure1-2yearsTherapy:ValvereplacementforsevereaorticstenosisOperativemortality(elderly)~4-24%/Morbidity~3-11%EventrateinasymptomaticsevereAS~1%/year

Valvular-heart-disease瓣膜性心脏疾病NaturalHistoryofAorticStenosisHeartfailurereduceslifeexpectancytolessthan2yearsAnginaandsyncopereducelifeexpectancybetween2and5yearsRateofprogression@0.1cm2/yearValvular-heart-disease瓣膜性心脏疾病ValvularHeartDisease

AorticRegurgitationValvular-heart-disease瓣膜性心脏疾病AorticRegurgitationEtiologyPhysicalExaminationAssessingSeverityNaturalHistoryPrognosisTimingofSurgeryValvular-heart-disease瓣膜性心脏疾病AorticRegurgitation:

EtiologyAnyconditionsresultinginincompetentaorticleafletsCongenitalBicuspidvalveAortopathyCysticmedialnecrosisCollagendisorders(e.g.Marfan’s)Ehler-DanlosOsteogenesisimperfectaPseudoxanthomaelasticumValvular-heart-disease瓣膜性心脏疾病AcquiredRheumaticheartdiseaseDilatedaorta(e.g.hypertension..)DegenerativeConnectivetissuedisordersE.g.ankylosingspondylitis,rheumatoidarthritis,Reiter’ssyndrome,Giant-cellarteritis)Syphilis(chronicaortitis)AcuteAI:aorticdissection,infectiveendocarditis,traumaAorticRegurgitation:

EtiologyValvular-heart-disease瓣膜性心脏疾病AorticRegurgitation

Pathophysiology:-LVreceivesbothbloodfromLA&AO

→volumeoverload→LVdilation→pulmonaryedema→relativeMR,MS;-Diastolicpressure↓,pulsepressure↑

Valvular-heart-disease瓣膜性心脏疾病AorticRegurgitation:

PhysicalExamWidenedpulsepressure Systolic–diastolic=pulsepressureHighpitched,blowing,decrescendodiastolicmurmuratLSBBestheardatend-expiration&leaningforwardHands&KneepositionS1

S2 S1Valvular-heart-disease瓣膜性心脏疾病AorticRegurgitat