第08章心脏瓣膜病.ppt

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,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

2、心脏瓣膜病,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,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,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 calci

3、fication (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,Pathophysiology(病理生理),The cross-sectional area of the mitral valve orifice (瓣环口面积） Normal adults 4 - 6cm Mild MS 2cm Moderate MS 1.5cm Severe 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,The effect on LA and c

4、ardiac 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,LA PVP、PCP lung congestion /pulmonary edema pulmonary artery in

5、tima 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,Remarks (备注),PAP：肺动脉压 PCP：肺毛细血管压 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,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) Hemop

6、tysis(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,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,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 (心尖区舒张期杂音），

7、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,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 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

8、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,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08章心脏瓣膜病,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

9、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,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

10、捻叁第08章心脏瓣膜病第08章心脏瓣膜病,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,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,Therapy(治疗),General therapy(一般治疗)：预防风湿热及感染性心内膜炎 Hemo

11、ptysis(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,Therapy(治疗),Acute pulmonary 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

12、病,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,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

13、 muscle (乳头肌) and LV. Every abnormality may 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,一、Chronic MI,Rheumatic heart disease: The leftlets of mitral valve fibrose , thicken, shorten and often accompany MS and aortic valve disease Mitral valve prolapse (二尖瓣脱垂) CHD：Chronic ischemia

14、(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,一、Chronic MI,Calcification of mitral ring and subvalvular (二尖瓣环及环下区钙化) Infective endocsrditis Rupture of chordae tendineae (unknown cause) LV enlarged significantly

15、 (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,二、Acute MI,Rupture of chordae tendineae (腱索断裂) Endocarditis leads to the leftlets of valve destruction (心内膜炎致瓣叶毁损) 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 pro

16、sthetic 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,Pathophysiology,MI LVEDV LV hypertrophy LVEDP, 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,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、Ph

17、ysical Sign Heaving apex impulse (抬举性心尖搏动) Cardiac sound：S1（重度MI），S2分裂，闻及S3 Cardiac 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,Laboratory examination,XRay ECG Echocardiogram 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

18、收缩期射流，半定量返流量,众靠蓑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,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， RV VSD（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章心脏瓣膜病第08章心脏瓣膜病,Systolic ejection murm

19、ur 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,Atrial fibrillation Infective endocarditis Embolism Heart failure,Complication,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,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

20、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,Therapy,Medical therapy (内科治疗) Prevent endocarditis and rheumatic fever Patients 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

21、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,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,Aortic Valve Disea

22、se,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,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,Etiology and Pathology,Rheumatic 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

23、 (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,Pathophysiology,The cross-sectional area of the aortic valve orifice (瓣环口面积） Normal adult 3.0cm The 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

24、脏瓣膜病第08章心脏瓣膜病,ASAfter loadingLV hypertrophyLVEDP,LA amplification PAP PCP Lung congestion and edema,Myocardial 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,Clinical situation,Symptom AS Triple syndrom (AS三联症) Dyspnoea (呼吸困难): Lung congestion Angi

25、na (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,Clinical situation,Physical sign Cardiac sound:S1 is normal ,S2 is paradoxical splitting(逆分裂), S4 may be heard Cardiac murmur:：SM is heard on the second intercostal space(肋间)of right border of sternum

26、 , 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第08章心脏瓣膜病第08章心脏瓣膜病,Laboratory examination,X-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

27、、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,Diagnosis and Differential diagnosis,Diagnosis 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 diagnosis AS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

28、章心脏瓣膜病,Complication,Arrhythmia：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 endocarditis Embolism Heart 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,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，远期存活率优于内科治疗,迢立炊馅息剥卯拖盎润虱砰呼浇噶

29、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,Medicine therapy,Principal 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,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

30、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,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,Etiology and pathology,一、Chronic AI （一）：Aortic valve disease Rheumatic 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

31、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,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AI Marfars 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 h

32、ypertension or atherosclerosis Idiopathic 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,Etiology and pathology,二、Acute AI Infective endocarditis Trauma Dissection of aorta (主动脉夹层分离):夹层血肿使主动脉瓣环扩大，或瓣叶、瓣环被夹层血肿撕裂，多见于马凡氏综合征、高血压或妊娠 Rupture of prosthetic valve

33、 (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,Pathophysiology,Chronic aortic regurgitationLVEDVSBP of LV after many years DBP of aortaangina LVEDP Pulse pressure LV dilating and hypertrophy 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0

34、8章心脏瓣膜病,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章心脏瓣膜病,Clinical situation,Physical Sign: SP, DP, PP 1. Peripheral vascular sign Water-hammer pulse (水冲脉) Pistol shot sound (枪击音) De musset signs (点头运动） Duroziez

35、 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,Clinical situation,Physical Sign 2. 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S3 4. 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

36、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,Laboratory examination,X-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,Diagnosis and Differential diagnosis,Diagnosis 典型杂音周围血管征 Differential diagnosis 与Graham St