心脏瓣膜病医学知识讲座专家讲座

ValvularHeartDiseaseCenterofWestChinaMedicalSciencesSichuanUniversity心脏瓣膜病医学知识讲座第1页【Pathology】Singleormultiplevalvesabnormalitiescausedbyinflamation、mucoiddegeneration,retrogration,

congenitalmalformation,ischemic

necrosisetc.

,whichcontributetostenosisandregurgitation.Rheumaticfever------applicationofpenecilinSyphilis-----controlofSTD

Calcificaorticstenosis-----populationaging回总表心脏瓣膜病医学知识讲座第2页ValvularHeartDiseaseMSMRARAS内科学教材心脏病学部分searchCategoryBeijingSATHENSatelliteEducationNetworkTechnologyCo.,LTD.心脏瓣膜病医学知识讲座第3页Section1.MitralValveDisease1.1MitralStenosis

(MS）心脏瓣膜病医学知识讲座第4页MitralStenosisMSsearch治疗临床表现分步总结左支气管受压症状预后UCG代偿期失代偿期心导管总论病理MS总目录全方面检验病生症状文字描述X－rayECG试验检验体征并发症判别诊疗诊疗病因闭式分离直视修补人工瓣膜球囊成形理想适应相对适应禁忌术前后对比手术疗效回四种瓣膜病表心脏瓣膜病医学知识讲座第5页MITRALSTENOSIS(VIEWEDFROMBELOWANDLEFT).Funnel-shapedstenosisDiscrete

membranous

stenosis(notshown)二狭病解前面观回总表心脏瓣膜病医学知识讲座第6页ThickedstenoticmitralEnlargementofleftatriumMitralorificeL.A.回总表心脏瓣膜病医学知识讲座第7页Normalmitralvalveorificearea(MVOA):4－6cm2Threestages:MVOA≤2cm2

（mildstenosis）MVOA≤1.5cm2

（moderatestenosis）MVOA≤1cm2

（severestenosis）CompensatedstageLeftatriumdecompensatedstageRightventriculardecompensatedstage记忆法2.01.51【Pathophysiology】回总表心脏瓣膜病医学知识讲座第8页病生分步总结回总表心脏瓣膜病医学知识讲座第9页①DyspnoeaDyspnoeaonexertion

Paroxysmalnocturnaldyspnea

（Vagushypertonic）Pulmonaryoedema1.Symptoms【Clinicalmanifestations】回总表心脏瓣膜病医学知识讲座第10页②Palpitationsorembolifromatrialfibrillation③Haemoptysis(咯血)④Recurrentbronchitisandchogh⑤

Crackdownsymptom(压迫症状)【Clinicalmanifestations】1.Symptoms回总表心脏瓣膜病医学知识讲座第11页AORTAL.PULMONARYARTERYL.MAINBRONCHUSL.UPPERPULMONARYVEINL.ATRIUMTheleftbronchuscaudaequinasyndrome左支气管受压综合征回总表心脏瓣膜病医学知识讲座第12页Compression

symptoms回总表心脏瓣膜病医学知识讲座第13页【Signs】

Presystolicaccentuation(收缩期前增强)Whenleftatrialcontractionweakenedthepresystolicaccentuationdisappear;Thelongerthemurmur,themoreseverethestenosis;Maycombinedwithdiastolicthrill.①Thecharacteristicdiastoliclowfrequency“rumble（隆隆样）”attheapex回总表心脏瓣膜病医学知识讲座第14页Diastolicmurmurs(Mildstenosis)敲ESC键则停顿声音播放回总表心脏瓣膜病医学知识讲座第15页Presystolicaccentuation---LatediastolicmurmurDM（晚期增强）敲ESC键则停顿声音播放回总表心脏瓣膜病医学知识讲座第16页【Signs】：

AuscultationLatediastolicrumble听取这种杂音时应注意哪几点？敲ESC键则停顿声音播放回总表心脏瓣膜病医学知识讲座第17页②AloudS1andtheopeningsnap(OS)(whichindicatesthevalvesaresoftandflexible).ThedistancebetweenS2andtheOAdecreasedastheLApressureelevated③

Pulmonaryhypertension:P2isloudandnormallysplit.SystolicmurmurRelative

pulmonary

incompetenceEarly-diastolicGraham–Steellmurmur【Signs】回总表心脏瓣膜病医学知识讲座第18页Openingsnapofmitralvalve(between2nd-3rdribsontheleftofsternum)OSOS敲ESC键则停顿声音播放回总表心脏瓣膜病医学知识讲座第19页Graham-SteellmurmurPulmonaryauscultationarea敲ESC键则停顿声音播放回总表Adiastolicblowingmurmurofpulmonaryinsufficiency心脏瓣膜病医学知识讲座第20页④中重度狭窄者呈二尖瓣面容Mitralface(malarflush)二、体征

Signs(续)

回总表心脏瓣膜病医学知识讲座第21页右室肥厚时胸骨左缘及剑突下收缩期抬举式搏动示意图假如自儿童期就有二尖瓣狭窄，因右室长大，可见心前区隆起心脏瓣膜病医学知识讲座第22页【Examination】LAenlargement

Pear-shapedheartMitralvalvecalcified

KerleyB线(中重度肺郁血时，肺门阴影显著加深，肺下部血

管影降低而上部增多)Haemosiderosis

(含铁血黄素沉积点状影)1.ChestX-ray回总表心脏瓣膜病医学知识讲座第23页ChestX-rayofrheumaticheartdiseaseTheenlargementoftherightportionofthecardiacsilhouette.TheLAappendageisdilatedandformsalocalizedbulge(arrow)ontheleftcardiacborder.左房正面观察心影右缘扩大左心耳扩大形成左心缘局部膨隆回总表心脏瓣膜病医学知识讲座第24页ECG回总表心脏瓣膜病医学知识讲座第25页Pmitrale(二尖瓣P波)

Af(Atrialfibrillation)RVhypertrophy2.

ECG【Examination】回总表心脏瓣膜病医学知识讲座第26页Ｍ型

正常二尖瓣前叶活动曲线EF斜率正常双峰存在前后瓣叶反向运动【Examination】3.Echocardiogram回总表心脏瓣膜病医学知识讲座第27页Ｍ-Mode二尖瓣前叶活动曲线因EF斜率减慢双峰消失呈城垛样前后瓣叶同向运动前叶增厚开放受限左房增大前叶后叶【Examination】3.Echocardiogram回总表心脏瓣膜病医学知识讲座第28页EchocardiogramofNormalMV【Examination】回总表心脏瓣膜病医学知识讲座第29页2Dlong-axis(open)EchocardiogramofMS击此键心室舒张回总表心脏瓣膜病医学知识讲座第30页2Dlong-axis(close)

EchocardiogramofMS击此键心室收缩回总表心脏瓣膜病医学知识讲座第31页2Dshort-axis(open)

EchocardiogramofMS击此键心室收缩回总表心脏瓣膜病医学知识讲座第32页2Dshort-axis(close)

EchocardiogramofMS击此键心室舒张回总表心脏瓣膜病医学知识讲座第33页Diagnosis&

Differentialdiagnosis

DiastolicrumbleinmitralareaandLAenlargement;

UCGforfurtherdiagnosis回总表心脏瓣膜病医学知识讲座第34页

Austin-Flint

murmur:causedbysevereaorticregurgitation.

Atrialmyxoma(心房粘液瘤)

MitralvalvecalcificationDifferentialdiagnosis:回总表心脏瓣膜病医学知识讲座第35页Austin-FlintmurmurAorticregurgitation;BloodflowbackandimpactagainsttheAMV;Causesrelativelymitralstenosis.击此键演动画心脏瓣膜病医学知识讲座第36页Austin-FlintmurmurAorticregurgitation;BloodflowbackandimpactagainsttheAMV;Causesrelativelymitralstenosis.击此键演动画心脏瓣膜病医学知识讲座第37页

ATRIALMYXOMA(心房粘液瘤)较罕见，可出现MS症状，体栓塞、全身不适及发烧等，可类似细菌性心内膜炎及SLE。肿瘤于舒张期进入二尖瓣口，收缩期进入心房，可出现特征性波状回波。如不手术切除，可造成死亡。Differentialdiagnosis:回总表心脏瓣膜病医学知识讲座第38页Myxoma心室收缩ATRIALMYXOMA带蒂左房粘液瘤随心室收缩和舒张上下活动击此键心室舒张回总表心脏瓣膜病医学知识讲座第39页Myxoma心室舒张ATRIALMYXOMA带蒂左房粘液瘤随心室收缩和舒张上下活动击此键心室收缩回总表心脏瓣膜病医学知识讲座第40页【Complication】

Atrialfibrillation(morethan50%):LVstrokevolumedecreaseby20%,whichinduceorworsentheHFSystemicembolism(20%)Pulmonaryinfection回总表心脏瓣膜病医学知识讲座第41页complicationsAcutepulmonaryedemaRightheartfailureEndocarditis:rare心脏瓣膜病医学知识讲座第42页THROMBUSATTACHEDTOPOSTERIORWALLOFL.ATRIUM,ANDTHROMBUSATPOSTEROMEDIALCOMMISSUREOFMITRALVALVE左房血栓脱落回总表心脏瓣膜病医学知识讲座第43页【Treatment】Acombinationofsurgeryandmedication;Preventionofcomplications;Oraldigoxinforchronicatrialfibrillation,andcardioversionifnecessary.回总表心脏瓣膜病医学知识讲座第44页【Treatmentfor

decompensatedstage】Preventionofthe

streptococcushemolyticusinfection;Prophylaxisagainsttherelapsesofrheumaticfever;Preventionofinfectiousendocarditis:preventiveusageofmedicinearoundthesurgery.回总表心脏瓣膜病医学知识讲座第45页【Treatmentfor

decompensatedstage】Properrest,limitthewaterintake,diuretics;Treatmentforacutepulmonaryedema;Managementofmassivehemoptysis

;AnticoagulationisnecessaryforAfpatients;

Arteryembolectomy(动脉切开取栓术)回总表心脏瓣膜病医学知识讲座第46页

l.Idealindications:①Simplemitralstenosis(moderate-severe)，NYHAI-III,andwithapparentsymptoms;②Valvesareelastic,withoutprominentcalcificationormalformation;MVOA≤1.5cm2,withoutthrombusinLA③

meanleftatrialpressure＞1.46kPa(11mmHg)，pressuredifferenceacrossthemitralvalveindiastole＞1.06kPa（3mmHg）。(经皮球囊扩张瓣膜成形术)【PercutaneousMitralBalloonValvulopastay】回总表心脏瓣膜病医学知识讲座第47页2，Relativeindications:RestenosisAtrialfibrillationMitralvalvecalcificationCombinedwithmitraloraorticregurgitationPulmonaryhypertensionHeartfailurePatientswhocannotaffordanticoagulationtreatment【PercutaneousMitralBalloonValvulopastay】(经皮球囊扩张瓣膜成形术)回总表心脏瓣膜病医学知识讲座第48页3.AbstinenceActiverheumatism,severearrhythmia,severeheartdysfunction,thrombosishistory；SevereMVcalcificationormalformation,combinedwithseveremitraloraorticregurgitation;

Leftatrialmuralthrombus;PatientswhoarewithcontraindicationforVentricularseptalpuncture【PercutaneousMitralBalloonValvulopastay】(经皮球囊扩张瓣膜成形术)回总表心脏瓣膜病医学知识讲座第49页【球囊扩张术疗效】平均瓣口面积可增加1Cm2。术后93~100%患者症状和心功效可改进。优点：创伤小、痛苦少，相对安全且康复快并发症：体循环栓塞、左心室穿孔、心包填塞、房缺、二尖瓣回流、室性心动过速和房性心律失常、房室传导阻滞、穿剌部位血管损伤、出血、低血压和球囊破裂等。术后1年有8%再狭窄。EffectofPMBV回总表心脏瓣膜病医学知识讲座第50页动画二尖瓣球囊成形术示意图回总表心脏瓣膜病医学知识讲座第51页二尖瓣球囊成形术球囊到位充盈时球囊中部被狭窄二尖瓣压迫成“腰征”球囊完全膨胀“腰征”消失回总表心脏瓣膜病医学知识讲座第52页ChestX-rayofPMBVpatient术前术后九个月回总表心脏瓣膜病医学知识讲座第53页【Surgicaltreatment】Indication：

SameasPMBV

Closedmitralcommissurotomy(闭式分离术)回总表心脏瓣膜病医学知识讲座第54页闭式分离术

（3／3）回总表心脏瓣膜病医学知识讲座第55页

对合并存在关闭不全可作适当缝补或进行瓣环成形术。【Surgicaltreatment】直视下修补术回总表心脏瓣膜病医学知识讲座第56页指征:心功效在3～4级且合并有显著主动脉瓣疾病或／及主动脉瓣回流造成左室显著增大，或瓣膜广泛重度钙化以致不能分离修补者以及钙化粥样瘤引发狭窄者均适用瓣膜替换术。

【Surgicaltreatment】人工瓣膜替换术回总表心脏瓣膜病医学知识讲座第57页机械瓣优点：耐用，不排异，不钙化缺点：终生抗凝，伴有溃疡病或出血性疾病者忌用，以后难再接收其它手术。【Surgicaltreatment】机械瓣替换术回总表心脏瓣膜病医学知识讲座第58页

生物瓣优点：术后不需长久抗凝，极少排异；缺点：可因感染性心内膜炎或在若干年后因钙化或/及机械性损伤而失效。【Surgicaltreatment】生物瓣替换术回总表心脏瓣膜病医学知识讲座第59页WestChinaMedicalCenterofsichuanUniversityMitralRegurgitation回四种瓣膜病表心脏瓣膜病医学知识讲座第60页【Etiology】Rheumatic

heartdiseaseMitralprolapseIschaemicpapillarymuscledysfunctionCardiomyopathyMarfan’ssyndromeInfectiousendocarditisand

chordae

tendincarupture(腱索断裂)心脏瓣膜病医学知识讲座第61页症状总结表早期无显著症状，可保持较长时间，甚至超出20年.一旦出现显著症状，多已经有不可逆心功损害。心悸咳嗽劳力性呼吸困难乏力，但急性肺水肿、咯血及栓塞少心脏瓣膜病医学知识讲座第62页【Clinicalmanifestation】

Signs：

murmur：

systolicmurmur

diastolicmurmur(

when

MRissevere)heartfailure(causedbyrelativemitralstenosismay)happened,murmurintensitydecreased.心脏瓣膜病医学知识讲座第63页收缩期杂音在心尖区听收缩期杂音敲ESC键则停顿声音播放心脏瓣膜病医学知识讲座第64页收缩期杂音心尖区收缩期杂音伴第三心音敲ESC键则停顿声音播放第三心音心脏瓣膜病医学知识讲座第65页2.

Signs②leftventricleenlargementinthelatestage心脏瓣膜病医学知识讲座第66页Leftventricularenlargement心尖搏动心脏瓣膜病医学知识讲座第67页【Examination】Ｘ-ray:leftatriumandventricleenlargementinlatestageECG:leftventricularenlargementandhypertrophy

UCG:helpfulindifferentiatingetiologyandevaluatingLVfunction.心脏瓣膜病医学知识讲座第68页X-RaychestL.andR.VentricularEnlargement心脏瓣膜病医学知识讲座第69页ECGElectrocardiographicEvidenceofL.VentricularHypertrophy(LargeSinV1,LargeRinV4)andMinorAtrialAbnormality(BroadP)心脏瓣膜病医学知识讲座第70页【Diagnosisand

differentialdiagnosis】Typicalsystolicmurmurattheapex;LVenlargementinthemiddle-latestage;

Distinguishfromothermurmurs:

1.physiologicmurmur2.mitralvalveprolapse(二尖瓣脱垂)

心脏瓣膜病医学知识讲座第71页收缩期杂音在心尖区听收缩期喀喇音和杂音敲ESC键则停顿声音播放心脏瓣膜病医学知识讲座第72页【Diagnosisand

differentialdiagnosis】UCGimageofmitralvalveprolapse

二尖瓣脱垂超声心动图表现二尖瓣前叶二尖瓣脱垂呈吊床样改变二尖瓣后叶心脏瓣膜病医学知识讲座第73页MitralValve

prolapse（二尖瓣脱垂

）latesystolicclicksCanbefoundintwoconditions:Valvewornout(middleagedandelderly),chordae

tendineaeandpapillary

musclesabnormal

afterinfarctionValvesaresoftinyouthespeciallythinwomenMaycombinedwitharrhythmia,syncope,untypicalchestpain,

transient

myocardial

ischemiaandinfectiousmyocarditis.心脏瓣膜病医学知识讲座第74页【Complication】Similartomitralvalvestenosis(relativelylatestage);

Infectiousmyocarditis（morecommonthaninMS)Thrombosisisraretosee心脏瓣膜病医学知识讲座第75页【Treatment

】

MedicaltherapySimilartomitralstenosis第一节回四种瓣膜病表心脏瓣膜病医学知识讲座第76页【Treatment

】

SurgicaltherapyValvereplacement：earlysurgery第二节回四种瓣膜病表心脏瓣膜病医学知识讲座第77页AorticvalvulardiseaseAorticStenosis(AS）回四种瓣膜病表心脏瓣膜病医学知识讲座第78页AORTICVALVE:FUSIONOFRIGHTCUSPANDPOSTERIORCUSP,RESULTINGINABICUSPIDVALVEWHICHISSTILLCOMPETENT病解：主动脉瓣狭窄：右瓣与后瓣粘连形成二叶式主动脉瓣心脏瓣膜病医学知识讲座第79页【Etiology】<60yRheumaticorcongenital;60～75yCalcifiedcongenitalbicuspidvalve(morecommoninman)>75yDegenerativecalcification(morecommoninwoman)心脏瓣膜病医学知识讲座第80页【Clinicalmanifestation】dyspneaAngina

(about50%patientssuffered)2/3were

combinedwithcoronaryarterydiseaseSyncope

laborinduced,maybethefirstsignSuddencardiacdeath心脏瓣膜病医学知识讲座第81页Mechanismofangina正常异常心脏瓣膜病医学知识讲座第82页【Clinicalmanifestation】Leftventricularenlargement(Sustainedandheavingapexbeat)SystolicejectionmurmurataorticareaandsystolicthrillThemurmurislouderifcombinedwithARThemurmurisweakerifcombinedwithHForMR。Themurmurintensitydoesn’tmatchtheseverityofstenosis，butdependsonstrokevolume心脏瓣膜病医学知识讲座第83页喷射性杂音在主动脉瓣副区听收缩中期喷射性杂音敲ESC键则停顿声音播放心脏瓣膜病医学知识讲座第84页S1

iscommonlynormal,whencombinedwithejectionsoundindicatesamildcalcificationandelasticvalves.A2

weakens(valvemovementislimited)S2

paradoxicalsplitting(delayedLVemptying)Auscultation:心脏瓣膜病医学知识讲座第85页【Diagnosisand

differentialdiagnosis】SystolicejectionmurmurataorticareaandsystolicthrillUCGmayhelptodistinguishtheetiologyDifferentiatefromhypertrophicobstructivecardiomyopathy心脏瓣膜病医学知识讲座第86页【Treatment】经皮球囊扩张瓣膜成形术有良好效果风湿性者不但常伴主动脉瓣关闭不全而且常伴二尖瓣病变，应全方面考虑。对暂无手术适应证无症状病人应依据狭窄程度适当限制体力活动。每六个月或一年复查，方便及时手术治疗。尤其注意预防感染性心内膜炎。慎用利尿剂和作用于小动脉血管扩张剂Medicaltreatment心脏瓣膜病医学知识讲座第87页AS

balloonangioplasty（1）心脏瓣膜病医学知识讲座第88页球囊瓣膜成形导管狭窄主动脉瓣导引钢丝AS

balloonangioplasty（2）心脏瓣膜病医学知识讲座第89页瓣膜狭窄程度重，变形显著，钙化重而广预计难以分离或合并显著关闭不全时均应作瓣膜替换术术前均应作心导管术及心血管造影术对老年人及有心绞痛史者应加作冠状动脉造影以全方面了解心脏冠脉结构及血流动力学情况风湿性者常合并二尖瓣病变，处理标准与无症状者同其症状究系由二尖瓣病变抑或AS引发，应全方面分析考虑【Treatment】Surgicaltreatment心脏瓣膜病医学知识讲座第90页AorticValvularIncompetenceAorticRegurgitation(AR)回四种瓣膜病表心脏瓣膜病医学知识讲座第91页病解AORTICINSUFFICIENCY:VALVEVIEWEDFROMABOVE,THICKENED,SHORTCUSPSWI