心 臟 瓣 膜 病 課件

ValvularHeartDisease心臟瓣膜病心臟瓣膜病

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(gè)或多個(gè)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。Mitralvalvedisease

二尖瓣疾病EtiologyandPathology

（病因和病理）Rheumaticheartdisease(風(fēng)濕性心臟病)Congenitalmalformation(先天性畸形)Senilemitralannulusandsubvalvularcalcification(老年人二尖瓣環(huán)及環(huán)下區(qū)鈣化)Pathophysiology(病理生理)Thecross-sectionalareaofthemitralvalveorifice(瓣環(huán)口面積）Normaladults4-6cm2MildMS≤2cm2ModerateMS≤1.5cm2SevereMS≤1.0cm2TheeffectonLAandcardiacoutputofMS

MildMS：LA壓力輕度升高，心排血量正常SevereMS：跨瓣壓差增大(20mmHg)→LA壓力升高（25mmHg)；休息時(shí)心排血量正?；驕p少TheeffectonthepulmonarycirculationandrespirationofelevatedleftatriumpressureRemarks(備注)PAP：肺動脈壓PCP：肺毛細(xì)血管壓PVP肺靜脈壓Clinicalsituation(臨床表現(xiàn))一、Symptom(中度狹窄始出現(xiàn)癥狀)Exertiondyspnea(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NLaboratoryexamination

(實(shí)驗(yàn)室檢查)X－Ray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ECGPⅡ>0.12s,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Cardiaccatheterization(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DiagnosisandDifferentialdiagnosis(診斷和鑒別)Diagnosis心尖區(qū)DM＋LA擴(kuò)大及實(shí)驗(yàn)室檢查可診斷，超聲有確診價(jià)值Differentialdiagnosis二尖瓣口血流增加AustinFlint雜音左房粘液瘤：隨體位改變的DMComplication（并發(fā)癥）四、Rightheartfailure(右心衰竭)五、Pulmonaryinfection(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7.4年死亡原因多為上述并發(fā)癥Therapy(治療)Generaltherapy(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Atrialfibrillation：快速心室率時(shí)應(yīng)用洋地黃Rightheartfailure：以利尿?yàn)橹鱉itralincompetence:MI

二尖瓣關(guān)閉不全EtiologyandPathology

（病因病理）Duringsystole,competence(關(guān)閉)ofmitralvalvedependontheintegrityofmitralstructureandfunction(includingleftletsofvalve,mitralannulus(瓣環(huán)),tendinouscords(腱索),papillarymuscle(乳頭肌)andLV.EveryabnormalitymayleadtoMI.一、ChronicMIRheumaticheartdisease:Theleftletsofmitralvalvefibrose,thicken,shortenandoftenaccompanyMSandaorticvalvediseaseMitralvalveprolapse(二尖瓣脫垂)CHD：Chronicischemia(缺血)orinfarction(梗死)leadtofibrosisandfunctionaldisorderofpapillarymuscle二、AcuteMIRuptureofchordaetendineae(腱索斷裂)Endocarditisleadstotheleftletsofvalvedestruction(心內(nèi)膜炎致瓣葉毀損)Acutemyocardialinfarction(急性心肌梗死)Traumaresultsinruptureofthemitralvalvecomponent(創(chuàng)傷使二尖瓣器破裂)Ruptureofprostheticvalve(人工瓣膜開裂)PathophysiologyMI→LVEDV↑→LVhypertrophy→LVEDP↑↑,LA↑↑→LVfailure→Pulmonarycongestion→PAP↑→RightheartfailureDiagnosisandDifferentialdiagnosis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：Tricuspidincompetence（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(shí)增強(qiáng)，伴頸靜脈收縮期搏動，RV↑↑VSD（室間隔缺損）Systolicejectionmurmurinleftborderofsternum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

AtrialfibrillationInfectiveendocarditis

EmbolismHeartfailureComplicationPrognosis急性嚴(yán)重返流者，若不及時(shí)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TherapyMedicaltherapy(內(nèi)科治療)PreventendocarditisandrheumaticfeverPatientswhoareasymptomaticandhavingnormalcardiacfunctionneedn’ttherapybutregularfollow-up(定期隨訪).Complicationarecuredinpatientswithcomplication.Surgicaltreatment

Prostheticvalvereplacement為主要手術(shù)方法，趨向早期手術(shù)有癥狀者應(yīng)在LVEF＜0.5，平均肺動脈壓＞20mmHg之前手術(shù)產(chǎn)生左室功能不全、LVEF0.3－0.5、年齡＞55歲、

LVEDD≥80mm，已不置換瓣

Valvuloplastyofmitralvalve(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AorticValveDisease主動脈瓣疾病Aorticstenosis(AS)主動脈瓣狹窄EtiologyandPathologyRheumaticheartdisease：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Congenitalbicuspidvalve(先天性二葉瓣)Senilecalcific(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PathophysiologyThecross-sectionalareaoftheaorticvalveorifice(瓣環(huán)口面積）Normaladult≥3.0cm2Thearea≤1.0cm2,LVSP↑,transvalvepressuregradientmanifest(跨瓣壓差明顯)AS→Afterloading↑→LVhypertrophy→LVEDP↑LAamplification↓PAPPCP↑↓LungcongestionandedemaMyocardialischemia↓Myocardialcontractility↓↓HeartfailureClinicalsituationSymptomASTriplesyndrom(AS三聯(lián)癥)Dyspnoea(呼吸困難):LungcongestionAngina(心絞痛)Causingby

Synocope(暈厥)cardiacoutput↓ClinicalsituationPhysicalsignCardiacsound:S1isnormal,S2isparadoxicalsplitting(逆分裂),S4maybeheardCardiacmurmur:：SMisheardonthesecondintercostalspace(肋間)ofrightborderofsternum,andradiatetocervicalpart(頸部),leftinferiorborderofsternumandcardiacapexaccompanyingthrillCardiacdilatation(心臟擴(kuò)大)，SBPandpulsepressuredecreaseLaboratoryexaminationX-Ray：心影可正?；蛏源?，晚期見肺淤血ECG：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Cardiaccatheterization：可根據(jù)左室-主動脈壓差計(jì)算瓣口面積

DiagnosisandDifferentialdiagnosisDiagnosis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DifferentialdiagnosisAS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InfectiveendocarditisEmbolismHeartfailure：發(fā)生左心衰后，病情迅速惡化Gastrointestinalhemorrhage(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?、猝死人工瓣膜置換術(shù)后，遠(yuǎn)期存活率優(yōu)于內(nèi)科治療MedicinetherapyPrincipalobjective：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(shí)轉(zhuǎn)復(fù)處理心衰PBAP:Percutaneousballoonaorticvalvuloplasty(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Aorticincompetence主動脈瓣關(guān)閉不全Etiologyandpathology一、ChronicAI（一）：AorticvalvediseaseRheumaticheartdisease: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Infectiveendocarditis:為單純AI的常見病因Congenitalmalformation: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Aorticvalvemucinousdegeneration(主動脈瓣粘液樣變性):可致主動脈瓣脫垂Etiologyandpathology（二）：Aortarootdilatation：瓣環(huán)擴(kuò)大，瓣葉關(guān)閉不全Syphiliticaortitis(梅毒性主動脈炎)：主動脈炎致主動脈根部擴(kuò)張,30%呈AIMarfar’ssyndrome：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SeverehypertensionoratherosclerosisIdiopathicdilatationofascendingaorta(特發(fā)性升主動脈擴(kuò)張)Etiologyandpathology二、AcuteAIInfectiveendocarditisTraumaDissectionofaorta(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

Ruptureofprostheticvalve(人工瓣膜破裂)PathophysiologyChronicaorticregurgitation→LVEDV↑→SBPofLV↑↓aftermanyyears↓DBPofaorta↓→anginaLVEDP↑↓↓Pulsepressure↑LVdilatingandhypertrophy↓↓PeripheralvascularsignLAP、PVP↑↓Leftheartfailure

Remarks(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Peripheralvascularsign：周圍血管征ClinicalsituationPhysicalSign:SP↑,DP↓,PP↑1.PeripheralvascularsignWater-hammerpulse(水沖脈)Pistolshotsound(槍擊音)Demussetsigns(點(diǎn)頭運(yùn)動）Duroziezsigns(杜氏雙重雜音)Capillarypulse(毛細(xì)血管搏動)Carotidarterypulse(頸動脈搏動)ClinicalsituationPhysicalSign2.Apicalimplusedisplacedtoleftanddown(心尖搏動向左下移位)3.Cardiacsound：S1、S2減弱，可聞及S34.Cardiacmurmur：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（AustinFlint雜音）LaboratoryexaminationX-Ray：急性者心臟大小正常；有肺淤血、肺水腫者，心胸比值增大，LV、LA增大，升主動脈擴(kuò)張及左心衰、肺淤血ECG：LV肥厚勞損Echocardiogram