1、1會計學(xué)瓣膜病的手術(shù)時機(jī)選擇瓣膜病的手術(shù)時機(jī)選擇Clinical follow-up, patient education, risk factor modification, annual echoSymptoms?Exercise testLV ejection fractionSevere valve calcification,rapid progression, and/or expected delays in surgeryYesLess than 0.50NormalNoPreoperative coronary angiographyClass Aortic Valve Re

2、placementClass bClass Class Class bSymptomsBPNormalEquivocalYesNoUndergoing CABGor other heart surgery?Severe Aortic Stenosis AVA less than 1.0 cm2Vmax greater than 4 m/sMean gradient 40 mmHg Re- evaluationClass IClass IIbClinical eval every 6 mo Echo every 6 moChronic Severe Aortic RegurgitationNoC

3、linical evaluation + EchoSymptoms?YesEquivocalExercise testLV function?EF borderline of uncertainNormal EFEF of 50% or lessRVG or MRILV dimensions?SD 45-50 mm or DD 60-70 mmNo symptomsSD 50-55 mm or DD 70-75 mmSD 45 mm or DD 60 mmSymptomsStable?YesClinical eval every 6 mo Echo every 12 mo No . or in

4、itial studyReevaluate and Echo 3moStable?Stable?Yes No . or initial studyReevaluate and Echo 3moClinical eval every 6-12 mo Echo every 12 moYesReevaluationConsider hemodynamic response to exerciseClass IIaSD 55 mm or DD 75 mmAbnormalNormalClass IAVRClass IMitral StenosisSymptoms?History, Physical ex

5、am CXR, ECG, 2D echa/DopplerAsymptomaticSymptomatic（ see Figures 6 and 7 ）Mild stenosisMVA 1.5 cm2Moderate or severe stenosis* MVA 1.5 cm2Valve morphologyfavorable for PMBV?PASP 50 mmHg ?ExerciseClass Class YesNoPoor exercise tolerance or PASP 60 mmHg or PAWP 25 mmHg YesNoNew-onset AF?Class bYesYesN

6、o Yearly follow-up History, Physical exam CXR . ECGNoConsiderPMBV Exclude LA clot. 3+ to 4+ MRSymptomatic Mitral Stenosis NYHA Funcltional ClassHistory phyaical exam, cxr,ecc,2D echo Doppler Mid stenosisMVA 1.5 cm2Moderate or severe stenosisMVA 1.5 cm2ExercisePSAP60mmHgPAWP25mmHgMVG15mmHgValve morph

7、ologyFavorable for PMBV?Valve morphologyFavorable for PMBV?Class IIbClass IClass IIaNoNoNoNoYesYesYesYesYearlyFollow-upSevere PHPAP60-80mm Hg6-monthFollow-up6-monthFollow-upConsiderPMBVConsiderCommissurotomyOr MVRExclude LA clot,3+ to 4+ MRNoYesLook for other causesPSAP60mmHgPAWP25mmHgMVG15mmHgValve

8、 morphologyFavorable for PMBV?Class bSymptomatic Mitral Stenosis NYHA Funcltional Class-History, phyaical exam, CXR, ECG, 2D echo/Doppler Mild stenosisMVA 1.5 cm2Moderate or severe stenosis *MVA 1.5 cm2ExerciseMitral valve repair or MVRClass NoYesClass aConsider PMBVExclude LA clot. 3+ to 4+ MRHigh-

9、 risksurgical candidate? NoClass YesChronic Severe Mitral RegurgitationClinical evaluation + EchoSymptoms?LV function?LV function?New onset AF?Pulmonary HT?MV repairlikely?Chordal preservation likely?NoYesYesYesYesNoNoNoMedical therapyEF 0.30ESD 55mmNormal LV functionEF 0.60ESD 40mmLV dysfunctionEF 0.60and/orESD 40mmE