《心脏瓣膜病》课件.ppt
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1、Valvular Heart Disease,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。,Mitral valve disease,二尖瓣疾病,Mitral stenosis(MS),二尖瓣狭窄,Etiology and Pathology(病因和病理),Rheumatic hear
2、t 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),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,The effect on LA and cardiac output of MS
3、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,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
4、衰竭),Remarks(备注),PAP:肺动脉压PCP:肺毛细血管压PVP肺静脉压,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,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,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
5、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),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,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 catheteriza
6、tion(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,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,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
7、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,Complication(并发症),四、Right heart failure(右心衰竭)五、Pulmonary infection(肺部感染),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,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
8、主,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,Mitral incompetence:MI,二尖瓣关闭不全,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 leftle
9、ts of valve,mitral annulus(瓣环),tendinous cords(腱索),papillary muscle(乳头肌)and LV.Every abnormality may lead to MI.,一、Chronic MI,Rheumatic 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:Chronic ischemia(缺
10、血)or infarction(梗死)lead to fibrosis and functional disorder of papillary muscle,一、Chronic MI,Calcification of mitral ring and subvalvular(二尖瓣环及环下区钙化)Infective endocsrditis Rupture of chordae tendineae(unknown cause)LV enlarged significantly(左室显著扩大)Else,二、Acute MI,Rupture of chordae tendineae(腱索断裂)En
11、docarditis 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 prosthetic valve(人工瓣膜开裂),Pathophysiology,MI LVEDV LV hypertrophy LVEDP,LALV failure Pulmonary congestion PAP Right heart fai
12、lure,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),S2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,Laboratory examination,XRayECGEchocardiogram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
13、勒:可用于二尖瓣心房侧探及收缩期射流,半定量返流量,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),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,Atrial fibrillation Infective endoca
14、rditis Embolism Heart failure,Complication,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,Therapy,Medical 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 p
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