1、Valvular Heart Disease心臟瓣膜病類型講解心臟瓣膜病 是指心瓣膜及瓣下裝置由于炎癥、變性、粘連、缺血性壞死、創(chuàng)傷、老化或鈣質(zhì)沉著及先天性發(fā)育異常等原因，使單個或多個瓣膜發(fā)生急性或慢性的狹窄或關(guān)閉不全，導(dǎo)致前向血流障礙和/或返流的一組疾病。臨床上最常受累的為二尖瓣，其次為主動脈瓣。風(fēng)濕性心臟病簡稱風(fēng)心病，仍是我國主要的心臟病，是風(fēng)濕性炎癥過程所致瓣葉損害。根據(jù)人群發(fā)病率調(diào)查已有下降趨勢。Mitral valve disease 二尖瓣疾病Mitral stenosis (MS)二尖瓣狹窄Etiology and Pathology（病因和病理）Rheumatic heart

2、disease (風(fēng)濕性心臟病)Congenital malformation (先天性畸形)Senile mitral annulus and subvalvular calcification (老年人二尖瓣環(huán)及環(huán)下區(qū)鈣化)Pathophysiology(病理生理)The cross-sectional area of the mitral valve orifice (瓣環(huán)口面積）Normal adults 4 - 6cmMild MS 2cmModerate MS 1.5cmSevere MS 1.0cmThe effect on LA and cardiac output of MS

3、 Mild MS：LA壓力輕度升高，心排血量正常Severe MS：跨瓣壓差增大(20mmHg) LA壓力升高（25mmHg)；休息時心排血量正?；驕p少The effect on the pulmonary circulation and respiration of elevated left atrium pressureLA PVP、PCP lung congestion /pulmonary edema pulmonary artery intima hyperplasia and thickening（肺動脈內(nèi)膜增生肥厚）PAP（肺動脈壓升高）Right heart failure（

4、右心衰竭）Remarks (備注)PAP：肺動脈壓PCP：肺毛細(xì)血管壓PVP肺靜脈壓Clinical situation(臨床表現(xiàn))一、Symptom (中度狹窄始出現(xiàn)癥狀)Exertion dyspnea(勞力性呼吸困難)Hemoptysis(咯血) 支氣管靜脈壓破裂出血 肺梗死 肺水腫Hoarseness（聲嘶）Cough(咳嗽） LA增大壓迫左主支氣管，支氣粘膜淤血水腫，易致感染 擴(kuò)大的LA、肺A壓迫喉返NClinical situation二、 Physical Sign(體征)Mitral facies (二尖瓣面容)S1，可聞及OS (開瓣音)Cardiac apex DM (心尖

5、區(qū)舒張期雜音），often accompanying diastolic thrill(舒張震顫）RV，P2 excessive(亢進(jìn))，Relative SM of TI(相對性三尖瓣關(guān)閉不全收縮期雜音)Laboratory examination(實(shí)驗(yàn)室檢查)XRay二尖瓣型心：左房右室大，主動脈結(jié)縮小，肺動脈擴(kuò)張，肺淤血ECG P0.12s, RV1,電軸右偏，心房纖顫，粗f波 Echocardiogram(超聲心動圖)：是確診、定量MS的可靠方法 M型：二尖瓣前后葉同向運(yùn)動 二維：狹窄瓣膜形態(tài)結(jié)構(gòu)，瓣口面積， 房室大小 連續(xù)多普勒：測定血流速度、跨瓣壓差Cardiac catheter

6、ization (心導(dǎo)管術(shù)) 測定肺毛細(xì)血管壓和左室壓，確定跨瓣壓差，明確狹窄程度Diagnosis and Differential diagnosis(診斷和鑒別)Diagnosis心尖區(qū)DMLA擴(kuò)大及實(shí)驗(yàn)室檢查可診斷，超聲有確診價值Differential diagnosis二尖瓣口血流增加Austin Flint雜音左房粘液瘤：隨體位改變的DMComplication（并發(fā)癥）一、Atrial fibrillation(心房纖顫)見于5%以上的患者；房顫使心排量下降20%，常是體力活動明顯受限的開始二、Acute pulmonary edema(急性肺水腫)為重度MS最嚴(yán)重的并發(fā)癥及致

7、死原因三、Embolism(栓塞)80%有房顫、大左房（D55mm)；2/3為腦栓塞，也可有周圍及內(nèi)臟栓塞Complication（并發(fā)癥）四、Right heart failure(右心衰竭)五、Pulmonary infection(肺部感染)Prognosis(預(yù)后)無癥狀者可存活多年，一旦有癥狀至致殘平均年死亡原因多為上述并發(fā)癥Therapy(治療)General therapy(一般治療)：預(yù)防風(fēng)濕熱及感染性心內(nèi)膜炎Hemoptysis(咯血)：減低肺靜脈壓力Atrial fibrillation：快速心室率時應(yīng)用洋地黃Right heart failure：以利尿?yàn)橹鱐herapy

8、(治療)Acute pulmonary edema：處理同急性左心衰；注意二尖瓣狹窄時用正性肌力藥物不好，僅當(dāng)房顫快速心室率時應(yīng)用Mechanic therapeutics (機(jī)械治療) MS：經(jīng)皮球囊二尖前瓣成型術(shù)；外科手術(shù)Mitral incompetence:MI二尖瓣關(guān)閉不全Etiology and Pathology（病因病理）During systole, competence (關(guān)閉) of mitral valve depend on the integrity of mitral structure and function (including leftlets of va

9、lve, mitral annulus (瓣環(huán)), tendinous cords (腱索), papillary muscle (乳頭肌) and LV. Every abnormality may lead to MI.一、Chronic MIRheumatic heart disease: The leftlets of mitral valve fibrose , thicken, shorten and often accompany MS and aortic valve diseaseMitral valve prolapse (二尖瓣脫垂)CHD：Chronic ischemi

10、a (缺血) or infarction (梗死) lead to fibrosis and functional disorder of papillary muscle一、Chronic MI Calcification of mitral ring and subvalvular (二尖瓣環(huán)及環(huán)下區(qū)鈣化)Infective endocsrditis Rupture of chordae tendineae (unknown cause) LV enlarged significantly (左室顯著擴(kuò)大) Else 二、Acute MIRupture of chordae tendine

11、ae (腱索斷裂)Endocarditis leads to the leftlets of valve destruction (心內(nèi)膜炎致瓣葉毀損)Acute myocardial infarction (急性心肌梗死)Trauma results in rupture of the mitral valve component (創(chuàng)傷使二尖瓣器破裂)Rupture of prosthetic valve (人工瓣膜開裂)PathophysiologyMI LVEDV LV hypertrophy LVEDP, LALV failure Pulmonary congestion PAP R

12、ight heart failureClinical situation(臨床表現(xiàn))一、Symptom輕度MI可終身無癥狀，嚴(yán)重MI心排血量減少，感乏力、呼吸困難二、Physical SignHeaving apex impulse (抬舉性心尖搏動)Cardiac sound：S1（重度MI），S2分裂，聞及S3Cardiac murmur：從S1后立即開始，與S2同時終止的SM，可伴收縮期震顫，向左腋 、左肩胛下區(qū)傳導(dǎo)；乳頭肌功能不全、腱索斷裂的雜音似海鷗鳴叫樣Laboratory examinationXRayECGEchocardiogram二維超聲：可顯示二尖瓣的形態(tài)結(jié)構(gòu)，提供心室大

13、小，明確病因彩超連續(xù)多普勒：可用于二尖瓣心房側(cè)探及收縮期射流，半定量返流量Diagnosis and Differential diagnosis心尖區(qū)SM心房、心室增大，診斷MI可成立，確診有賴于超聲心動圖應(yīng)與以下情況相鑒別：Tricuspid incompetence（三尖瓣關(guān)閉不全）：胸左緣4、5肋間SM，可傳至心尖區(qū)，雜音吸氣時增強(qiáng)，伴頸靜脈收縮期搏動， RVVSD（室間隔缺損）Systolic ejection murmur in left border of sternum生理性雜音功能性雜音主、肺動脈根部擴(kuò)張左或右室流出道梗阻 Atrial fibrillation Infect

14、ive endocarditis Embolism Heart failureComplicationPrognosis急性嚴(yán)重返流者，若不及時手術(shù)，極難存活慢性MI無癥狀期長，一旦發(fā)生左心衰竭，預(yù)后不良TherapyMedical therapy (內(nèi)科治療)Prevent endocarditis and rheumatic feverPatients who are asymptomatic and having normal cardiac function neednt therapy but regular follow-up (定期隨訪).Complication are cur

15、ed in patients with complication.Surgical treatment Prosthetic valve replacement為主要手術(shù)方法，趨向早期手術(shù)有癥狀者應(yīng)在LVEF，平均肺動脈壓 20mmHg之前手術(shù)產(chǎn)生左室功能不全、年齡55歲、 LVEDD80mm，已不置換瓣 Valvuloplasty of mitral valve (二尖瓣整復(fù)術(shù))優(yōu)點(diǎn)：不需長期抗凝，LV功能恢復(fù)較好Aortic Valve Disease主動脈瓣疾病Aortic stenosis (AS)主動脈瓣狹窄Etiology and PathologyRheumatic heart

16、disease ：風(fēng)濕性炎癥所致瓣膜交界處融合、瓣葉纖維化、鈣化，引起瓣葉狹窄畸形，多伴AI及二尖瓣損害Congenital bicuspid valve (先天性二葉瓣)Senile calcific (degenerative) AS (退行性老年鈣化性主動脈瓣狹窄)：65歲老年人AS的常見原因，瓣葉主動脈面鈣化結(jié)節(jié)限制瓣葉活動PathophysiologyThe cross-sectional area of the aortic valve orifice (瓣環(huán)口面積）The area 1.0cm,LVSP,transvalve pressure gradient manifest

17、(跨瓣壓差明顯)ASAfter loadingLV hypertrophyLVEDP LA amplification PAP PCP Lung congestion and edemaMyocardial ischemia Myocardial contractility Heart failureClinical situationSymptomAS Triple syndrom (AS三聯(lián)癥)Dyspnoea (呼吸困難): Lung congestionAngina (心絞痛) Causing by Synocope (暈厥) cardiac outputClinical situat

18、ionPhysical signCardiac sound:S1 is normal ,S2 is paradoxical splitting(逆分裂), S4 may be heardCardiac murmur:：SM is heard on the second intercostal space(肋間)of right border of sternum , and radiate to cervical part (頸部), left inferior border of sternum and cardiac apex accompanying thrill Cardiac dil

19、atation(心臟擴(kuò)大)，SBP and pulse pressure decreaseLaboratory examinationX-Ray：心影可正?；蛏源螅砥谝姺斡傺狤CG：可有左室肥厚勞累征，及各種心律失常Echocardiogram：為確定、定量AS的重要方法Cardiac catheterization：可根據(jù)左室-主動脈壓差計(jì)算瓣口面積Diagnosis and Differential diagnosisDiagnosis典型的收縮期雜音，易于診斷；多瓣膜病變提示風(fēng)心病單純AS：根據(jù)年齡，應(yīng)考慮單葉瓣、二葉瓣膜及老年退行性變，確診有賴于超聲心動圖Differential d

20、iagnosisAS應(yīng)與左室流出道梗阻性疾病鑒別ComplicationArrhythmia：10%可發(fā)生房顫、室性心律失常、房室傳導(dǎo)阻滯，可至猝死、暈厥Infective endocarditisEmbolismHeart failure：發(fā)生左心衰后，病情迅速惡化Gastrointestinal hemorrhage(胃腸道出血)： 15-20%胃腸道血管發(fā)育不良Prognosis一旦出現(xiàn)癥狀，平均壽命僅三年。死亡原因?yàn)椋鹤笮乃ァ⑩廊斯ぐ昴ぶ脫Q術(shù)后，遠(yuǎn)期存活率優(yōu)于內(nèi)科治療Medicine therapyPrincipal objective：確定狹窄發(fā)生度、觀察病情進(jìn)展，爭取手術(shù)機(jī)會擇期

21、手術(shù)Methods預(yù)防感染性心內(nèi)膜炎、風(fēng)濕熱AS不能耐受房顫，一旦出現(xiàn)即時轉(zhuǎn)復(fù)處理心衰PBAP: Percutaneous balloon aortic valvuloplasty (經(jīng)皮球囊主動脈瓣成形術(shù))適用于高齡患者、不宜換瓣及妊娠等情況，作為姑息治療Aortic incompetence主動脈瓣關(guān)閉不全Etiology and pathology一、Chronic AI（一）：Aortic valve diseaseRheumatic heart disease:占2/3，由于瓣葉纖維化、增厚縮短，影響閉合，常合并AS及二尖瓣損害Infective endocarditis: 為單純A

22、I的常見病因Congenital malformation : 先天性二葉瓣、室間隔缺損伴一葉瓣脫垂、先天性主動脈瓣穿孔Aortic valve mucinous degeneration (主動脈瓣粘液樣變性): 可致主動脈瓣脫垂Etiology and pathology（二）： Aorta root dilatation ：瓣環(huán)擴(kuò)大，瓣葉關(guān)閉不全Syphilitic aortitis (梅毒性主動脈炎)： 主動脈炎致主動脈根部擴(kuò)張 ,30%呈AIMarfars syndrome：為遺傳性結(jié)締組織病，升主動脈呈梭形擴(kuò)張，常伴二尖瓣脫垂Severe hypertension or ather

23、osclerosisIdiopathic dilatation of ascending aorta (特發(fā)性升主動脈擴(kuò)張)Etiology and pathology二、Acute AIInfective endocarditisTraumaDissection of aorta (主動脈夾層分離):夾層血腫使主動脈瓣環(huán)擴(kuò)大，或瓣葉、瓣環(huán)被夾層血腫撕裂，多見于馬凡氏綜合征、高血壓或妊娠 Rupture of prosthetic valve (人工瓣膜破裂)PathophysiologyChronic aortic regurgitationLVEDVSBP of LV after many

24、 years DBP of aortaangina LVEDP Pulse pressure LV dilating and hypertrophy Peripheral vascular sign LAP、PVP Left heart failureRemarks (備注)SBP：收縮壓DBP：舒張壓PVP：肺靜脈壓LAP：左房壓 LVEDP：左室舒張末壓Peripheral vascular sign：周圍血管征Clinical situationPhysical Sign: SP, DP, PP 1. Peripheral vascular signWater-hammer pulse

25、(水沖脈)Pistol shot sound (槍擊音)De musset signs (點(diǎn)頭運(yùn)動）Duroziez signs (杜氏雙重雜音)Capillary pulse (毛細(xì)血管搏動)Carotid artery pulse (頸動脈搏動)Clinical situationPhysical Sign2. Apical impluse displaced to left and down(心尖搏動向左下移位)3. Cardiac sound：S1、S2減弱，可聞及S34. Cardiac murmur：舒張?jiān)缙陔s音，吹風(fēng)性，呼氣末期易聞及，于左胸第三肋間明顯。重度返流者，心尖區(qū)可聞及舒張?jiān)缙诼÷与s音（Austin Flint雜音）Laboratory examinationX-Ray：急性者心臟