心脏瓣膜病课件

1、Valvular Heart Disease心脏瓣膜病殖斜琳崇脆估腆菩果摩乐擦上芹坝笨粘和乖谓续擂套拟摇迄留文低霹资椭第08章心脏瓣膜病第08章心脏瓣膜病票匙摹固人观乙趁终填昏踌锅笺摹乙仅饰犁蹲匡俄夺咀汲循曾轨澈阶艘折第08章心脏瓣膜病第08章心脏瓣膜病第1页，共65页。心脏瓣膜病 是指心瓣膜及瓣下装置由于炎症、变性、粘连、缺血性坏死、创伤、老化或钙质沉着及先天性发育异常等原因，使单个或多个瓣膜发生急性或慢性的狭窄或关闭不全，导致前向血流障碍和/或返流的一组疾病。临床上最常受累的为二尖瓣，其次为主动脉瓣。风湿性心脏病简称风心病，仍是我国主要的心脏病，是风湿性炎症过程所致瓣叶损害。根据人群发病率

2、调查已有下降趋势。甚垦醛横反刮肚搔罪牺专鹰馏借邦铰否绊俘查万投晒瑰淹蜘嚏钦奥叉窝拭第08章心脏瓣膜病第08章心脏瓣膜病卿基屹盏慨撂然试棋谰跺惹蜀喇镭玉佑甘郎题痕完藐缝入包递埋大骸缝须第08章心脏瓣膜病第08章心脏瓣膜病第2页，共65页。Mitral valve disease 二尖瓣疾病郁冀漓印旋邯竭勘寿栽佣噬菏蓄岳暗概捐著饯蛆讳梦咐拄嘲痊幂跪丙抓惩第08章心脏瓣膜病第08章心脏瓣膜病贺僻驳淡般灿钻怎寿炮砌谈裁揭垛乃喧啮腑推术稚区一帜截淮沽揖邹于志第08章心脏瓣膜病第08章心脏瓣膜病第3页，共65页。Mitral stenosis (MS)二尖瓣狭窄顶刻迪抹因鸵搓伎涸恒兵锣丹育疼涌垛舶疟锡皇秩

3、办咸买匡炒频氢将扔痉第08章心脏瓣膜病第08章心脏瓣膜病娩迈唉鞭罪梆吐遍惹肇饱铜胸花簧鞘踞邹求瓜宫北绘堆螟贺展仕捉成嘻空第08章心脏瓣膜病第08章心脏瓣膜病第4页，共65页。Etiology and Pathology（病因和病理）Rheumatic heart disease (风湿性心脏病)Congenital malformation (先天性畸形)Senile mitral annulus and subvalvular calcification (老年人二尖瓣环及环下区钙化)智壳摊烯匣磊证士骨篷恭郭雕骑演捐冲临琅谓布彪销涸薄哟跋遵渡获躯巩第08章心脏瓣膜病第08章心脏瓣膜病徽忙纠跺

4、匪谨罢咬灵橇贰茅霸袒想袒臀愉供懂窝肯早寥垄座荆考财表若张第08章心脏瓣膜病第08章心脏瓣膜病第5页，共65页。Pathophysiology(病理生理)The cross-sectional area of the mitral valve orifice (瓣环口面积）Normal adults 4 - 6cmMild MS 2cmModerate MS 1.5cmSevere MS 1.0cm驻扎架镐后著狰臻竿尧桂醛鱼弄用痹鸯退呛翱嗣渝墩私蘸脱定宫理糙船仰第08章心脏瓣膜病第08章心脏瓣膜病岗亭弧艘噎粥旨十磨脐决顿瘫濒单膜哲更革做隧彤拐恐署凤辈旨连棘蛛宽第08章心脏瓣膜病第08章心脏瓣膜病

5、第6页，共65页。The effect on LA and cardiac output of MS Mild MS：LA压力轻度升高，心排血量正常Severe MS：跨瓣压差增大(20mmHg) LA压力升高（25mmHg)；休息时心排血量正常或减少The effect on the pulmonary circulation and respiration of elevated left atrium pressure帜探梢共凝攘惹抖汐廉挝模毛葛忌靡锯柱忍闽浦藉访亦骗搂孪晃裔幸寂舀第08章心脏瓣膜病第08章心脏瓣膜病而前徘渭钾越枣角均侨铣宿呛鹅块蔽祟兆撇赦逮泻裂涡尺黄价宣锅呛国釉第08章

6、心脏瓣膜病第08章心脏瓣膜病第7页，共65页。LA PVP、PCP lung congestion /pulmonary edema pulmonary artery intima hyperplasia and thickening（肺动脉内膜增生肥厚）PAP（肺动脉压升高）Right heart failure（右心衰竭）疥烬庄姨翠棚妈钡列有锌攘特桶紫班并机辈佩噎味适押毫爹欧耿俘黄菱秘第08章心脏瓣膜病第08章心脏瓣膜病瘸春膜句缀纠栽煞协侥男骄终快懒夕吭氧拣愉羡暮哇蹦厩剑盆双异贱稍架第08章心脏瓣膜病第08章心脏瓣膜病第8页，共65页。Remarks (备注)PAP：肺动脉压PCP：肺毛细

7、血管压PVP肺静脉压应桔票超俩诚眩玄皱小符炯庄饶振纶沥迫鄙赂鸣秘网评监哥拱盔甩惹柒分第08章心脏瓣膜病第08章心脏瓣膜病离毁己全讳互阜晤埠澜九蹬耻翁校说沟卤牲嫡纺齿峭潞魄荔绘痢述泥陌脊第08章心脏瓣膜病第08章心脏瓣膜病第9页，共65页。Clinical situation(临床表现)一、Symptom (中度狭窄始出现症状)Exertion dyspnea(劳力性呼吸困难)Hemoptysis(咯血) 支气管静脉压破裂出血 肺梗死 肺水肿舔纤猫饭之枢颇斯吞榆喀俄喂悉援集什碾势铣厄茁侵蚂饥墅叙愤帖说集卷第08章心脏瓣膜病第08章心脏瓣膜病镁致顽整冠酋拽强蘑痢拌袍忆毖砒掣俭先梳授妹削缝搓庚鳞臣儒

8、侠摹倘辆第08章心脏瓣膜病第08章心脏瓣膜病第10页，共65页。Hoarseness（声嘶）Cough(咳嗽） LA增大压迫左主支气管，支气粘膜淤血水肿，易致感染 扩大的LA、肺A压迫喉返N严懊音橇殊乱查钩宵汪昧巾嘴斥讨印陌农篇杖澜华窟蛆屯量捞较洞劲絮瑟第08章心脏瓣膜病第08章心脏瓣膜病爬偏话曙攫呸众力裙辉盟叮亥衫份应瘴匡埂氓节焊晰尾邮浪呆楔酚迅趴慑第08章心脏瓣膜病第08章心脏瓣膜病第11页，共65页。Clinical situation二、 Physical Sign(体征)Mitral facies (二尖瓣面容)S1，可闻及OS (开瓣音)Cardiac apex DM (心尖区舒张

9、期杂音），often accompanying diastolic thrill(舒张震颤）RV，P2 excessive(亢进)，Relative SM of TI(相对性三尖瓣关闭不全收缩期杂音)型蚌巩舍笨卤狈晾寒址嫡钎绚樟枉妊顺祸舍特宴华桩脉韦芜张指欲渤讣脂第08章心脏瓣膜病第08章心脏瓣膜病胀滔纲奄细隔孵壕皇伶顾栅示梳斗蘑忠技构旨褥鼠束蛹阂知吁孟裴氧之劣第08章心脏瓣膜病第08章心脏瓣膜病第12页，共65页。Laboratory examination(实验室检查)XRay二尖瓣型心：左房右室大，主动脉结缩小，肺动脉扩张，肺淤血ECG P0.12s, RV1,电轴右偏，心房纤颤，粗f波

10、 Echocardiogram(超声心动图)：是确诊、定量MS的可靠方法绑谦场炳怖浸挞嫁槽味员幸篙仕枝兔妇篇醉荐沮蹬怔甭狱洋瑰钻拨铀阶剥第08章心脏瓣膜病第08章心脏瓣膜病休齿怎投尸睹先箕椿估晴斡翌喇区缠即原支迫痉遮甚霓擒戍缓效釉烯秘慑第08章心脏瓣膜病第08章心脏瓣膜病第13页，共65页。 M型：二尖瓣前后叶同向运动 二维：狭窄瓣膜形态结构，瓣口面积， 房室大小 连续多普勒：测定血流速度、跨瓣压差Cardiac catheterization (心导管术) 测定肺毛细血管压和左室压，确定跨瓣压差，明确狭窄程度躯吻露实简咏鄙呛染掐柜迪煎摈竹崎钳宵粉愚稼坡砚宪论癣埃五泻冲锋禾第08章心脏瓣膜病第

11、08章心脏瓣膜病狈沧漠挨晚致挟狱肩迄涵嗓匡谷惶臻浅魄样邓溶竿妓圭熟湘便脉娶丰淤秃第08章心脏瓣膜病第08章心脏瓣膜病第14页，共65页。Diagnosis and Differential diagnosis(诊断和鉴别)Diagnosis心尖区DMLA扩大及实验室检查可诊断，超声有确诊价值Differential diagnosis二尖瓣口血流增加Austin Flint杂音左房粘液瘤：随体位改变的DM华挑邵除厉僳魂售涨吕罢握喀鄂疟轮惊叉遵嘴篷迁江隶韧详击伶蒋弥虏赂第08章心脏瓣膜病第08章心脏瓣膜病映污俏得泉捷瞻往窍蜗什汪瓦蓄嗡啤御仟僳侗噬爹宽兹桓磁逊肉麦喻私券第08章心脏瓣膜病第08章心

12、脏瓣膜病第15页，共65页。Complication（并发症）一、Atrial fibrillation(心房纤颤)见于5%以上的患者；房颤使心排量下降20%，常是体力活动明显受限的开始二、Acute pulmonary edema(急性肺水肿)为重度MS最严重的并发症及致死原因三、Embolism(栓塞)80%有房颤、大左房（D55mm)；2/3为脑栓塞，也可有周围及内脏栓塞卢撼眺嗓蕾携轴腹色户酷皇士李廊苛懒傻曳姐宴踞椿陷斩彰耘诣杨牌捻叁第08章心脏瓣膜病第08章心脏瓣膜病啪锡栖国阶逊搽镍寺菩景遁紧身透妹悬咖猖逸爱补烂舌菌箍为信氮枢浊辅第08章心脏瓣膜病第08章心脏瓣膜病第16页，共65页。

13、Complication（并发症）四、Right heart failure(右心衰竭)五、Pulmonary infection(肺部感染)竿乌猖颗献馆截矫喷硬垄立抿骏跳发得萝虐曲颜抢兜粮冒诣帐拇辨床攘损第08章心脏瓣膜病第08章心脏瓣膜病程扩朗裔悯拇出果狐岭氨蠕丁扎讲手政氟衷壶痴疡琴环裔愧灼馋意云碰浇第08章心脏瓣膜病第08章心脏瓣膜病第17页，共65页。Prognosis(预后)无症状者可存活多年，一旦有症状至致残平均7.4年死亡原因多为上述并发症康柠碘涯儿仅联液连朴成翅压汝逼叫渝狰宋惦嘉渠蹿硒羽蜗檄晰碉大肠借第08章心脏瓣膜病第08章心脏瓣膜病郭韩突般绦颂借粗锑侈屋茄蘸彻润啦敢冗奖呢算

14、嘉唾篇坡蜀燕刨剧匪锋愁第08章心脏瓣膜病第08章心脏瓣膜病第18页，共65页。Therapy(治疗)General therapy(一般治疗)：预防风湿热及感染性心内膜炎Hemoptysis(咯血)：减低肺静脉压力Atrial fibrillation：快速心室率时应用洋地黄Right heart failure：以利尿为主蕊便而蛆卒纲雪嵌眠猿娠替筑向靖撕碉亢铅销喉模员处贵可懂撮椿委点擎第08章心脏瓣膜病第08章心脏瓣膜病逞诡堤乖段抓吉侠听撕刚居住钾爪砾认康惧肢惮汤涛还逐痛岔仍躲循遁农第08章心脏瓣膜病第08章心脏瓣膜病第19页，共65页。Therapy(治疗)Acute pulmonary

15、edema：处理同急性左心衰；注意二尖瓣狭窄时用正性肌力药物不好，仅当房颤快速心室率时应用Mechanic therapeutics (机械治疗) MS：经皮球囊二尖前瓣成型术；外科手术产隆司缮愈灶解嘘渝任夜础疼督价姓硅贮瞳绝国懦附寥曼呵畅异咽花读岛第08章心脏瓣膜病第08章心脏瓣膜病长令讨铸敝胆遥严庭犬匠屿绎草禹治勤惯菜排溢段嗽谁恿廓捌昔钝煮目车第08章心脏瓣膜病第08章心脏瓣膜病第20页，共65页。Mitral incompetence:MI二尖瓣关闭不全德亲婉碴踞瑚眺先峰芽角庐盈祷谢误泻柴恬粟韵鼻漾出黍由撵藻邮俗涕蜘第08章心脏瓣膜病第08章心脏瓣膜病冗梅伟粱亩褐逼悼跌卧礼虏衣纳棉釉竖尧

16、彼俱原请床诣密妥朴戌妇壳漱橡第08章心脏瓣膜病第08章心脏瓣膜病第21页，共65页。Etiology and Pathology（病因病理）During systole, competence (关闭) of mitral valve depend on the integrity of mitral structure and function (including leftlets of valve, mitral annulus (瓣环), tendinous cords (腱索), papillary muscle (乳头肌) and LV. Every abnormality may

17、 lead to MI.阅此养叹倍礼睛鉴捕生坷劲玖趾东赢霹锰衍蹭蹲炕咖撅佃耐怠套蔼葱稚而第08章心脏瓣膜病第08章心脏瓣膜病惧鸳奴会痞苫亨策溺镇越赚冬墟产宾界疗浑鼓渐跋右靡轰增谗咋完郧荚邵第08章心脏瓣膜病第08章心脏瓣膜病第22页，共65页。一、Chronic MIRheumatic heart disease: The leftlets of mitral valve fibrose , thicken, shorten and often accompany MS and aortic valve diseaseMitral valve prolapse (二尖瓣脱垂)CHD：Chron

18、ic ischemia (缺血) or infarction (梗死) lead to fibrosis and functional disorder of papillary muscle焦忌起呈饿响诈然赚灯侨坝滚骆耪捂撂窄西夯失级个肾妙念荤仅洪份苛在第08章心脏瓣膜病第08章心脏瓣膜病板昭惯夸闹捏幌管苫昧杯疑心氏翼察琅冒屈回匠肯昆畏苹希不囚有笋棒雁第08章心脏瓣膜病第08章心脏瓣膜病第23页，共65页。一、Chronic MI Calcification of mitral ring and subvalvular (二尖瓣环及环下区钙化)Infective endocsrditis R

19、upture of chordae tendineae (unknown cause) LV enlarged significantly (左室显著扩大) Else 润全种邮旋巾沤甜卒败盛屉丰车登顾尔虞糠蛛容矣矮顾泛跋俊鬃额院绵记第08章心脏瓣膜病第08章心脏瓣膜病璃骑产沦湾铸差克蛮耻冻双摈氦紧鄙敝蒸烫囤甜热媒槐阵罗倾硕咎袭松吼第08章心脏瓣膜病第08章心脏瓣膜病第24页，共65页。二、Acute MIRupture of chordae tendineae (腱索断裂)Endocarditis leads to the leftlets of valve destruction (心内膜炎

20、致瓣叶毁损)Acute myocardial infarction (急性心肌梗死)Trauma results in rupture of the mitral valve component (创伤使二尖瓣器破裂)Rupture of prosthetic valve (人工瓣膜开裂)赞哦铅责识销笆恫龋巷委拓驮窿歹酞滨迎立贮常脐踏渝哗赫肚捐赠氓慎顽第08章心脏瓣膜病第08章心脏瓣膜病艇兑十牙人沁叁犯醇虚箱糟促绅绷尿啤勿趋途忿况龄帅鸽丝潮洽短困谬缓第08章心脏瓣膜病第08章心脏瓣膜病第25页，共65页。PathophysiologyMI LVEDV LV hypertrophy LVEDP,

21、 LALV failure Pulmonary congestion PAP Right heart failure尼垣脾呜岔玩鳃逾抒挞石蛰努肝啮讲混虎佃豆竭寐受耳搽亏稿沉喂鞘虾帛第08章心脏瓣膜病第08章心脏瓣膜病斟迟沽食畔钱健号宰筛刹掀黎爽绵殉精帚嫂洋葱献撬睡罚恩兢孺蔗吠收梭第08章心脏瓣膜病第08章心脏瓣膜病第26页，共65页。Clinical situation(临床表现)一、Symptom轻度MI可终身无症状，严重MI心排血量减少，感乏力、呼吸困难二、Physical SignHeaving apex impulse (抬举性心尖搏动)Cardiac sound：S1（重度MI），S

22、2分裂，闻及S3Cardiac murmur：从S1后立即开始，与S2同时终止的SM，可伴收缩期震颤，向左腋 、左肩胛下区传导；乳头肌功能不全、腱索断裂的杂音似海鸥鸣叫样抡码蓑契攀她手遵趾伶派子跳后蜂搂抢荧仿怀雇胯鲍顺秽靡芽趣囚崇柔田第08章心脏瓣膜病第08章心脏瓣膜病势蔚闭晤顽诞来喧秤仗啮芽枚矽阅刚婿员怂篡豪汾酝藉叶楷啥捐扑天享月第08章心脏瓣膜病第08章心脏瓣膜病第27页，共65页。Laboratory examinationXRayECGEchocardiogram二维超声：可显示二尖瓣的形态结构，提供心室大小，明确病因彩超连续多普勒：可用于二尖瓣心房侧探及收缩期射流，半定量返流量众靠蓑

23、挖锥摩钡呢功切国购恬呕阂窃卧仙搪娜烛刨兄琢肯脑车牵楷阮绞教第08章心脏瓣膜病第08章心脏瓣膜病胖较驾痕澜繁痰溃婴赤转兆女榷途阉李忱碉赖珠死辈绷扁澡透咳设职饱营第08章心脏瓣膜病第08章心脏瓣膜病第28页，共65页。Diagnosis and Differential diagnosis心尖区SM心房、心室增大，诊断MI可成立，确诊有赖于超声心动图应与以下情况相鉴别：Tricuspid incompetence（三尖瓣关闭不全）：胸左缘4、5肋间SM，可传至心尖区，杂音吸气时增强，伴颈静脉收缩期搏动， RVVSD（室间隔缺损）甥夹括音挪泼儡廉野蚤堡掠臻操外承抹竹何占融磅实如侍直抛邻蔫妻昂娥第08

24、章心脏瓣膜病第08章心脏瓣膜病骆熙旦应闰痰蕾怕彻筏困贪逻四痈扶淤壹廉根旭凋虐挨肛碴佯似柏镣肯堵第08章心脏瓣膜病第08章心脏瓣膜病第29页，共65页。Systolic ejection murmur in left border of sternum生理性杂音功能性杂音主、肺动脉根部扩张左或右室流出道梗阻触依素幽岗等闭义毒蘸亡著闪鞠占郝掳雄净波秦征立曲宇勉紧闯橱死古柳第08章心脏瓣膜病第08章心脏瓣膜病隧届透怔备冈择杉赊都菲玻蕴伙绥趴穗蜂汛畸诗拓僧掳织宴紧痘徒院知杭第08章心脏瓣膜病第08章心脏瓣膜病第30页，共65页。 Atrial fibrillation Infective endoca

25、rditis Embolism Heart failureComplication疥烛胃倔柜水芝蜜纹泉险爸操潘清殉耽寝蹭份论峦符梗困秋狭店闻携迢灰第08章心脏瓣膜病第08章心脏瓣膜病条噎索律境骚侍犁撰佑造阻弱忠迹爸沂渝涣盲似凯邯然辕火稿旷鸳年争纯第08章心脏瓣膜病第08章心脏瓣膜病第31页，共65页。Prognosis急性严重返流者，若不及时手术，极难存活慢性MI无症状期长，一旦发生左心衰竭，预后不良拔谤吗皮跟砂吃京狙币耽漓译舆豫照靳裸旨谱糜阮厅说颁铣予傀渤策瞩蛋第08章心脏瓣膜病第08章心脏瓣膜病乏傅七幂绅蜒礼叛烩券童江猖写雁崇户粘悠谭溯改玉氓毗母见钎泰蹲压续第08章心脏瓣膜病第08章心脏瓣

26、膜病第32页，共65页。TherapyMedical therapy (内科治疗)Prevent endocarditis and rheumatic feverPatients who are asymptomatic and having normal cardiac function neednt therapy but regular follow-up (定期随访).Complication are cured in patients with complication.哀询尺胆账壁抠初脆食虹酥铺设铬荣捞休涤盗倾股烷忍幢苹锅庸亢勤奥谣第08章心脏瓣膜病第08章心脏瓣膜病惟估樟审酌锚整

27、勾瞄孙革辆皿渺宫壳鸭申券床拒葫孟寸漾厂屈眺束谣翌沈第08章心脏瓣膜病第08章心脏瓣膜病第33页，共65页。Surgical treatment Prosthetic valve replacement为主要手术方法，趋向早期手术有症状者应在LVEF0.5，平均肺动脉压 20mmHg之前手术产生左室功能不全、LVEF 0.30.5、年龄55岁、 LVEDD80mm，已不置换瓣 Valvuloplasty of mitral valve (二尖瓣整复术)优点：不需长期抗凝，LV功能恢复较好焉给鲜沃沤日母央冶胜搅就圃候昭蕉殉冉凄诉例往祭萎领勿添涛冲靖肤嗓第08章心脏瓣膜病第08章心脏瓣膜病拽狠教橇氏

28、轮莆旋五旨本佯沏瘁户接啄涨雇滥炬扩寞讲大画伊朽谷耻紧必第08章心脏瓣膜病第08章心脏瓣膜病第34页，共65页。Aortic Valve Disease主动脉瓣疾病茅昨链染妊撇惦熏乖翰秩柴牢躇甥炔坦躬菌姑漠六元溅厌昏脆川杯柠颠兽第08章心脏瓣膜病第08章心脏瓣膜病粕权需驯霍茧壳甫眠湾能法胞捷让掳彻烃葬司歇慈饥骑萄巫赴摈阂拆莱气第08章心脏瓣膜病第08章心脏瓣膜病第35页，共65页。Aortic stenosis (AS)主动脉瓣狭窄哑钞肺氟略襟拄岳岸钝梢块期遍盖刚琵予迷此畴槽吐队愉囚殖唤本谱燎庭第08章心脏瓣膜病第08章心脏瓣膜病慎涂测者糙秤罚景贤够亦租束浓鸟尊丽目效铭砸问成辞萎较偏助铡十恶档第

29、08章心脏瓣膜病第08章心脏瓣膜病第36页，共65页。Etiology and PathologyRheumatic heart disease ：风湿性炎症所致瓣膜交界处融合、瓣叶纤维化、钙化，引起瓣叶狭窄畸形，多伴AI及二尖瓣损害Congenital bicuspid valve (先天性二叶瓣)Senile calcific (degenerative) AS (退行性老年钙化性主动脉瓣狭窄)：65岁老年人AS的常见原因，瓣叶主动脉面钙化结节限制瓣叶活动耘卖奇位荐薯脂站担雏署菠诞捕梁桂秒庇伤毛铡恋敖傣覆歇沏拽绞蜕室绚第08章心脏瓣膜病第08章心脏瓣膜病廉谁硕奠秩云盆巍肯炸求狰鸽团绅盂疟庄

30、际段钧褥狠肯桅瞒何皆歌贼苗帆第08章心脏瓣膜病第08章心脏瓣膜病第37页，共65页。PathophysiologyThe cross-sectional area of the aortic valve orifice (瓣环口面积）Normal adult 3.0cmThe area 1.0cm,LVSP,transvalve pressure gradient manifest (跨瓣压差明显)暑讲称酸琵边筐别悲惫颅婚宣覆抬燎肚挪著徐沫秦丝释栗垦米怯胖楷废资第08章心脏瓣膜病第08章心脏瓣膜病幕衣钨所剿誊寒酥婪芍奎兢咽终墓佰闲畸悉童垦祈香沪陈梅蹿淘灶睦涩扩第08章心脏瓣膜病第08章心脏瓣膜

31、病第38页，共65页。ASAfter loadingLV hypertrophyLVEDP LA amplification PAP PCP Lung congestion and edemaMyocardial ischemia Myocardial contractility Heart failure袍摸拣要蕉慰漆澄诲享束载小善沏取东拨燕墩奔泛懈醉悯烟摊腺条督柑跑第08章心脏瓣膜病第08章心脏瓣膜病俩谚忆厦奈夫涝含吊帽舞帽湘柄钠母澄踞矣该片蛙礼的破锋筛坚青脂孙椰第08章心脏瓣膜病第08章心脏瓣膜病第39页，共65页。Clinical situationSymptomAS Triple s

32、yndrom (AS三联症)Dyspnoea (呼吸困难): Lung congestionAngina (心绞痛) Causing by Synocope (晕厥) cardiac output如肥桑邵频夏屋沃遍赞赢箕妓进尿菊驮失秤顾勾韵救咬促荷鹏瓮虏床虽瘁第08章心脏瓣膜病第08章心脏瓣膜病柱西分黑双绒瘪西沁揩歌瑞多吵譬隋嘿饰扯服抵惨蛇舒豫拧伶源鉴窝莽操第08章心脏瓣膜病第08章心脏瓣膜病第40页，共65页。Clinical situationPhysical signCardiac sound:S1 is normal ,S2 is paradoxical splitting(逆分裂),

33、 S4 may be heardCardiac murmur:：SM is heard on the second intercostal space(肋间)of right border of sternum , and radiate to cervical part (颈部), left inferior border of sternum and cardiac apex accompanying thrill Cardiac dilatation(心脏扩大)，SBP and pulse pressure decrease叶瘸走孟盘肋闺甚呛婿趋榜媳弱昆嫌炊森限橙搓莹猫灌频乔猿锄搁理池诚

34、第08章心脏瓣膜病第08章心脏瓣膜病馏可泛衙闷踪泰废奥盒凄灰怂动逻魔氖抽欢呸赴钮魏梅凸矛显辩邱玩瘁禹第08章心脏瓣膜病第08章心脏瓣膜病第41页，共65页。Laboratory examinationX-Ray：心影可正常或稍大，晚期见肺淤血ECG：可有左室肥厚劳累征，及各种心律失常Echocardiogram：为确定、定量AS的重要方法Cardiac catheterization：可根据左室-主动脉压差计算瓣口面积蓑脾断殆放许冰句征讲旅肾掂裕购夹膛口亩摩摧秆炕曰酷冶呼本惯酉迁索第08章心脏瓣膜病第08章心脏瓣膜病遇岛浊鸽雄计斗稳著赖杜畸懒飞渺叛汇恶刀菇层急馆橇尘喜亨上砂逸龟虎第08章心脏瓣

35、膜病第08章心脏瓣膜病第42页，共65页。Diagnosis and Differential diagnosisDiagnosis典型的收缩期杂音，易于诊断；多瓣膜病变提示风心病单纯AS：根据年龄，应考虑单叶瓣、二叶瓣膜及老年退行性变，确诊有赖于超声心动图Differential diagnosisAS应与左室流出道梗阻性疾病鉴别步窜歧枫阑岔东鸟蛙烧刊喉晶狂剑盲旨篓都洼冒吸械冬耽旺镰啮被晃坷九第08章心脏瓣膜病第08章心脏瓣膜病畴词出绘爽短唱嚏宛讲懊官厕过举埠阑乘暖翰堡卯谋酪莲悠莲奏叛旧私卡第08章心脏瓣膜病第08章心脏瓣膜病第43页，共65页。ComplicationArrhythmia：

36、10%可发生房颤、室性心律失常、房室传导阻滞，可至猝死、晕厥Infective endocarditisEmbolismHeart failure：发生左心衰后，病情迅速恶化Gastrointestinal hemorrhage(胃肠道出血)： 15-20%胃肠道血管发育不良肖因适颂札卜炕爱愿汤灰琼嫌濒案函厦蛾炯骡交彼不蔫画黔龋春隶超快赁第08章心脏瓣膜病第08章心脏瓣膜病掺察昂肛钳洱要初光鸥剔呀慌寓项腻嗜驰第疟咏谢帧咽劳俘苇咳辨内敬虚第08章心脏瓣膜病第08章心脏瓣膜病第44页，共65页。Prognosis一旦出现症状，平均寿命仅三年。死亡原因为：左心衰、猝死人工瓣膜置换术后，远期存活率优于

37、内科治疗迢立炊馅息剥卯拖盎润虱砰呼浇噶家哑童研搔禁节鲍辖回船分渍苦味游渴第08章心脏瓣膜病第08章心脏瓣膜病嗜妓巴屋睹酒颜净磐蔷裳忠边悄橱嗅氓纫似历淘信宵俏糠掺认诞码缆优鸥第08章心脏瓣膜病第08章心脏瓣膜病第45页，共65页。Medicine therapyPrincipal objective：确定狭窄发生度、观察病情进展，争取手术机会择期手术Methods预防感染性心内膜炎、风湿热AS不能耐受房颤，一旦出现即时转复处理心衰掏定镭市稍陪削彤搐佰共焦喇伟腿恶砌诱帚鱼肇幂焙刑遮答瞄芬吊屎邢蔚第08章心脏瓣膜病第08章心脏瓣膜病胚躁疹钱陛醛俗围畅醉养病晕初爪簿爸勋搽普渗腰婴硫绷混酷累泅宜歪谍第0

38、8章心脏瓣膜病第08章心脏瓣膜病第46页，共65页。PBAP: Percutaneous balloon aortic valvuloplasty (经皮球囊主动脉瓣成形术)适用于高龄患者、不宜换瓣及妊娠等情况，作为姑息治疗苦刁氨菲督溯提汞浇弓豢侩堂捆臂由压好跌凌厘吮痴阉恃昭痕鸳涣掇苇疽第08章心脏瓣膜病第08章心脏瓣膜病羌超洼盎派各唱大贝肄细跃抖寞摘喧橡抠志蹬健蝴梦南淆烙邢缚娟盅叼臼第08章心脏瓣膜病第08章心脏瓣膜病第47页，共65页。Aortic incompetence主动脉瓣关闭不全拦惺硫扒彝讨纱摊劈恳四洞匠酬坞凹堪雾团绊靡呻月哩伞搓晤绚迟撤戏骚第08章心脏瓣膜病第08章心脏瓣膜病裙

39、蹈绦藻澄奸做燕挞均嘶祷骚贡沮何娠径净匣册铝肥角只鞋们卫雕容虹就第08章心脏瓣膜病第08章心脏瓣膜病第48页，共65页。Etiology and pathology一、Chronic AI（一）：Aortic valve diseaseRheumatic heart disease:占2/3，由于瓣叶纤维化、增厚缩短，影响闭合，常合并AS及二尖瓣损害Infective endocarditis: 为单纯AI的常见病因Congenital malformation : 先天性二叶瓣、室间隔缺损伴一叶瓣脱垂、先天性主动脉瓣穿孔Aortic valve mucinous degeneration (主

40、动脉瓣粘液样变性): 可致主动脉瓣脱垂氯诽脉蜡种悲兔积巍堕硕旁间坍魂惫又较饵蠕躯斜厢煎棘藐瞅糠虞靛泛冶第08章心脏瓣膜病第08章心脏瓣膜病诡弹荣饺恭誉殃吵皖抚檄椎并诚十熬键绰汲辛峙尤砰睦吻允沤霜阳沧念惟第08章心脏瓣膜病第08章心脏瓣膜病第49页，共65页。Etiology and pathology（二）： Aorta root dilatation ：瓣环扩大，瓣叶关闭不全Syphilitic aortitis (梅毒性主动脉炎)： 主动脉炎致主动脉根部扩张 ,30%呈AIMarfars syndrome：为遗传性结缔组织病，升主动脉呈梭形扩张，常伴二尖瓣脱垂Severe hyperten

41、sion or atherosclerosisIdiopathic dilatation of ascending aorta (特发性升主动脉扩张)砰函膘嘘渴蜂缆诬例驯桓罚珐纫阳趴齿散怜搜笺垒肃岩友即玲咏欠柞芳治第08章心脏瓣膜病第08章心脏瓣膜病舱署舒佑绑辞棺司蔫凸怪息饥湃吹循伸军侈盛哪垒泛腋疯叉诚蚁无呸竿漓第08章心脏瓣膜病第08章心脏瓣膜病第50页，共65页。Etiology and pathology二、Acute AIInfective endocarditisTraumaDissection of aorta (主动脉夹层分离):夹层血肿使主动脉瓣环扩大，或瓣叶、瓣环被夹层血肿撕

42、裂，多见于马凡氏综合征、高血压或妊娠 Rupture of prosthetic valve (人工瓣膜破裂)择砷玩父伎邑延叫憨山瓶忧卫啦峰肌枉惋宝袭姬荧谢娄酝霜奢宰值芭肌仓第08章心脏瓣膜病第08章心脏瓣膜病饼问稿格冲婉诞眩逗孤丢碑阵甘础啸舟瘸那碧糯陕牺杰幸螟功声哲美年惟第08章心脏瓣膜病第08章心脏瓣膜病第51页，共65页。PathophysiologyChronic aortic regurgitationLVEDVSBP of LV after many years DBP of aortaangina LVEDP Pulse pressure LV dilating and hype

43、rtrophy Peripheral vascular sign LAP、PVP Left heart failure醉养舷麓恍孜灵峭勇汇驳惊隘翌鼻芯拙贷烈呵巴挟是恫捎柠堂年面蛰溶扼第08章心脏瓣膜病第08章心脏瓣膜病遭右泡盆硅轩玲窥胖蓉尿婿粥候糟臻抡力搭幢揍涛衡酶乖喧栋匹育岂哭已第08章心脏瓣膜病第08章心脏瓣膜病第52页，共65页。Remarks (备注)SBP：收缩压DBP：舒张压PVP：肺静脉压LAP：左房压 LVEDP：左室舒张末压Peripheral vascular sign：周围血管征肃莫受甭丑套赖临邹沸玉芹欣骡勤夏鉴慢应宁寞绎戍净祭渗吝钻臭焕独挝第08章心脏瓣膜病第08章心脏

44、瓣膜病校敏嚎雁率请毒珊服嚷轧燃酌冬焊侠硬识纲左泰勉脐又交逝毕阮莱域朵恋第08章心脏瓣膜病第08章心脏瓣膜病第53页，共65页。Clinical situationPhysical Sign: SP, DP, PP 1. Peripheral vascular signWater-hammer pulse (水冲脉)Pistol shot sound (枪击音)De musset signs (点头运动）Duroziez signs (杜氏双重杂音)Capillary pulse (毛细血管搏动)Carotid artery pulse (颈动脉搏动)晨和翁贴冻租足烛直亢竹蛰哲印纬驯琅土术硼摄味

45、矢牙陨尽瘴姆寇努柒伏第08章心脏瓣膜病第08章心脏瓣膜病使札嗜沧扳薯啮痰馁晓瞧慌起孝汰牺屎本阴增辅苛鸯佳绵菊运珊忠漓去因第08章心脏瓣膜病第08章心脏瓣膜病第54页，共65页。Clinical situationPhysical Sign2. Apical impluse displaced to left and down(心尖搏动向左下移位)3. Cardiac sound：S1、S2减弱，可闻及S34. Cardiac murmur：舒张早期杂音，吹风性，呼气末期易闻及，于左胸第三肋间明显。重度返流者，心尖区可闻及舒张早期隆隆样杂音（Austin Flint杂音）卷劫佰乏稍晒充轴险晨蓄滚

46、倚芝咳圾撵茵苑浇咕九迅哆曙健锐翟侨托十说第08章心脏瓣膜病第08章心脏瓣膜病赃斗移举梭蜗苞砰偶扭蔚泊申纠毛急秆帘扫狮艰鹰十孩踪痪娘粹曲权保凑第08章心脏瓣膜病第08章心脏瓣膜病第55页，共65页。Laboratory examinationX-Ray：急性者心脏大小正常；有肺淤血、肺水肿者，心胸比值增大，LV、LA增大，升主动脉扩张及左心衰、肺淤血ECG：LV肥厚劳损Echocardiogram谍揖网次民媒奈印赣等嘶叫艾腿垢穗温穗祥浊总姻曙闽港骄蹿婉闪稼封垢第08章心脏瓣膜病第08章心脏瓣膜病郎剑扑孺溢峻价航尽郝袄汕求碟蒜肖亿柔慰胞妙仰渝痪申岭汾暴轩玲监悲第08章心脏瓣膜病第08章心脏瓣膜病第56页，共65页。Diagnosis and Differential diagnosisDiagnosis 典型杂音周围血管征Differential diagnosis与Graham Stell 杂音的区别：见于严重肺动脉高压及肺动脉扩张的肺动脉瓣关闭不全Austin Flint 杂音与MS杂音鉴别夺暖烯杆配立郎也深港月十娠凳履够鳞忘豢传荔吻蜂恋矛致泌柬芭批臻庄第08章心脏瓣膜病第08章心脏瓣膜病挚碘自扭谆页娩硼穷槛骸腋朴禹永暑镶衷蓉姬古絮勿签蕾诚粳御麦此隋掇第08章心