第08章 心脏瓣膜病

ValvularHeartDisease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。Mitralvalvedisease二尖瓣疾病Mitralstenosis(MS)二尖瓣狭窄EtiologyandPathology（病因和病理）Rheumaticheartdisease(风湿性心脏病)Congenitalmalformation(先天性畸形)Senilemitralannulusandsubvalvularcalcification(老年人二尖瓣环及环下区钙化)Pathophysiology(病理生理)Thecross-sectionalareaofthemitralvalveorifice(瓣环口面积）Normaladults4-6cm²MildMS≤2cm²ModerateMS≤1.5cm²SevereMS≤1.0cm²TheeffectonLAandcardiacoutputofMSMildMS：LA压力轻度升高，心排血量正常SevereMS：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TheeffectonthepulmonarycirculationandrespirationofelevatedleftatriumpressureLA→PVP、PCP→lungcongestion/pulmonaryedemapulmonaryarteryintimahyperplasiaandthickening（肺动脉内膜增生肥厚）PAP（肺动脉压升高）Rightheartfailure（右心衰竭）Remarks(备注)PAP：肺动脉压PCP：肺毛细血管压PVP肺静脉压Clinicalsituation(临床表现)一、Symptom(中度狭窄始出现症状)1.Exertiondyspnea(劳力性呼吸困难)2.Hemoptysis(咯血)支气管静脉压↑破裂出血肺梗死肺水肿3.Hoarseness（声嘶）4.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NClinicalsituation二、PhysicalSign(体征)Mitralfacies(二尖瓣面容)S1↑，可闻及OS(开瓣音)CardiacapexDM(心尖区舒张期杂音），oftenaccompanyingdiastolicthrill(舒张震颤）RV↑，P2excessive(亢进)，RelativeSMofTI(相对性三尖瓣关闭不全收缩期杂音)Laboratoryexamination(实验室检查)X－Ray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PⅡ0.12s,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Cardiaccatheterization(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DiagnosisandDifferentialdiagnosis(诊断和鉴别)Diagnosis心尖区DM＋LA扩大及实验室检查可诊断，超声有确诊价值Differentialdiagnosis二尖瓣口血流增加AustinFlint杂音左房粘液瘤：随体位改变的DMComplication（并发症）一、Atrialfibrillation(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、Acutepulmonaryedema(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（D﹥55mm)；2/3为脑栓塞，也可有周围及内脏栓塞Complication（并发症）四、Rightheartfailure(右心衰竭)五、Pulmonaryinfection(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)1.Generaltherapy(一般治疗)：预防风湿热及感染性心内膜炎2.Hemoptysis(咯血)：减低肺静脉压力3.Atrialfibrillation：快速心室率时应用洋地黄4.RightheartfailureTherapy(治疗)4.Acutepulmonaryedema：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5.Mechanictherapeutics(机械治疗)MS：经皮球囊二尖前瓣成型术；外科手术Mitralincompetence:MI二尖瓣关闭不全EtiologyandPathology（病因病理）Duringsystole,competence(关闭)ofmitralvalvedependontheintegrityofmitralstructureandfunction(includingleftletsofvalve,mitralannulus(瓣环),tendinouscords(腱索),papillarymuscle(乳头肌)andLV.EveryabnormalitymayleadtoMI.一、ChronicMI1.Rheumaticheartdisease:Theleftletsofmitralvalvefibrose,thicken,shortenandoftenaccompanyMSandaorticvalvedisease2.Mitralvalveprolapse(二尖瓣脱垂)3.CHD：Chronicischemia(缺血)orinfarction(梗死)leadtofibrosisandfunctionaldisorderofpapillarymuscle一、ChronicMI4.Calcificationofmitralringandsubvalvular(二尖瓣环及环下区钙化)5.Infectiveendocsrditis6.Ruptureofchordaetendineae(unknowncause)7.LVenlargedsignificantly(左室显著扩大)8.Else二、AcuteMI1.Ruptureofchordaetendineae(腱索断裂)2.Endocarditisleadstotheleftletsofvalvedestruction(心内膜炎致瓣叶毁损)3.Acutemyocardialinfarction(急性心肌梗死)4.Traumaresultsinruptureofthemitralvalvecomponent(创伤使二尖瓣器破裂)5.Ruptureofprostheticvalve(人工瓣膜开裂)PathophysiologyMI→LVEDV↑→LVhypertrophy→LVEDP↑↑,LA↑↑→LVfailure→Pulmonarycongestion→PAP↑→RightheartfailureClinicalsituation(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、PhysicalSignHeavingapeximpulse(抬举性心尖搏动)Cardiacsound：S1↓（重度MI），S2分裂，闻及S3Cardiacmurmur：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LaboratoryexaminationX－Ray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收缩期射流，半定量返流量DiagnosisandDifferentialdiagnosis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：1.Tricuspidincompetence（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↑↑2.VSD（室间隔缺损）3.Systolicejectionmurmurinleftborderofsternum•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AtrialfibrillationInfectiveendocarditisEmbolismHeartfailureComplicationPrognosis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Medicaltherapy(内科治疗)PreventendocarditisandrheumaticfeverPatientswhoareasymptomaticandhavingnormalcardiacfunctionneedn’ttherapybutregularfollow-up(定期随访).Complicationarecuredinpatientswithcomplication.SurgicaltreatmentProstheticvalvereplacement为主要手术方法，趋向早期手术有症状者应在LVEF＜0.5，平均肺动脉压＞20mmHg之前手术产生左室功能不全、LVEF0.3－0.5、年龄＞55岁、LVEDD≥80mm，已不置换瓣Valvuloplastyofmitralvalve(二尖瓣整复术)优点：不需长期抗凝，LV功能恢复较好AorticValveDisease主动脉瓣疾病Aorticstenosis(AS)主动脉瓣狭窄EtiologyandPathology1.Rheumaticheartdisease：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2.Congenitalbicuspidvalve(先天性二叶瓣)3.Senilecalcific(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PathophysiologyThecross-sectionalareaoftheaorticvalveorifice(瓣环口面积）Normaladult≥3.0cm²Thearea≤1.0cm²,LVSP↑,transvalvepressuregradientmanifest(跨瓣压差明显)AS→Afterloading↑→LVhypertrophy→LVEDP↑LAamplification↓PAPPCP↑↓LungcongestionandedemaMyocardialischemia↓Myocardialcontractility↓↓HeartfailureClinicalsituationSymptomASTriplesyndrom(AS三联症)Dyspnoea(呼吸困难):LungcongestionAngina(心绞痛)CausingbySynocope(晕厥)cardiacoutput↓ClinicalsituationPhysicalsign1.Cardiacsound:S1isnormal,S2isparadoxicalsplitting(逆分裂),S4ma