二尖瓣及主动脉瓣疾病的诊断与治疗

1. 二尖瓣及主动脉瓣疾病的诊断与治疗 浙江大学医学院附属第一医院 张芙荣

2. Valvular heart disease • MITRAL STENOSIS • AORTIC STENOSIS • MITRAL REGURGITATION -Acute and Chronic • AORTIC REGURGITATION -Acute and Chronic • TRICUSPID REGURGITATION • TRICUSPID STENOSIS • PULMONARY STENOSIS • PULMONARY REGURGITATION • MIXED LESIONS

4. 病因和流行病学 • 病因：风湿性疾病，退行性疾病，感染性疾病，炎症性疾病，新型瓣膜病（如AIDS，药源性以及遗传性） • 流行病学： Bernard Iunga*, A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. European Heart Journal (2003) 24, 1231–1243

5. 总 论 病人评估： 诊断 ↓ 严重程度评估 ↓ 预后评估 ↓ 干预指征

6. Strategy for Evaluating Heart Murmurs Bonow, R. O. et al. J Am Coll Cardiol 2008;52:e1-e142

8. Cardiac murmurs Cardiac murmurs are often the first sign of underlying valvular disease. May be systolic or diastolic, pathological or benign. Systolic murmurs may be due to physiological increases in blood velocity or might indicate as yet asymptomatic cardiac disease. Diastolic murmurs are usually pathological and require further evaluation. ECG and CXR are readily available, but provide limited information.

9. 临床评估 • 症状分析 • 体征：杂音 • 超声心动图 KEY TO DIAGNOSIS与患者临床情况相结合 评估内容： 所有瓣膜及升主动脉、房室大小和功能 狭窄性瓣膜病：瓣膜开口面积，平均压差，最大流速 返流性瓣膜病：ERO TEE：血栓形成，人工瓣膜功能障碍，感染性心内膜炎，手术结果监测 3D超声：解剖结构评估

10. 临床评估 • X线→钙化评估 • 放射核素造影→窦律下EF值评估（返流性VHD） • 负荷试验→ 负荷ECG：潜在症状，AS风险分层 负荷超声心动图：返流量改变的评估 • CT→钙化评估，CTA可排除CAD • MRI→作为超声的替代，对某些指标较精确 • 生化指标→BNP CAG：术前排除CAD • 心导管：非侵入性检查不理想时可考虑

11. Mitral Stenosis

12. Mitral Stenosis Etiology • Rheumatic (nearly all adult MS) • other etiologies are very rare: • Degenerative (Mitral valve annular calcification,elderly) • Congenital (parachute MV), MS+atrial septal defect=Lutembacher syndrome. • Others: post-inflammatory, metabolic syndromes , Other causes of LV inflow obstr.,atrial myxoma, LA ball thrombus, cor triatriatum.etc.

14. MITRAL STENOSIS-Pathology Posterior cusp Fusion of the comissures, cusps or chords. Contracture and thickening of the cusps. Shortening and fusion of the chordae tendinae. Funnel –shaped orifice. Mitral annulus Anterior cusp Chordae tendinae Papillary muscles

15. Mitral Stenosis Overview • Definition: Obstruction of LV inflow that prevents proper filling during diastole • Normal MV Area: 4-6 cm2 • Transmitral gradients and symptoms begin at areas less than 2 cm2 • Rheumatic carditis is the predominant cause • Prevalence and incidence: decreasing due to a reduction of rheumatic heart disease.

16. Pathophysiology • Obstruction between LA and LV. • Pressure gradient. • Elevated LA pressure. • LA pressure increases at elevated HR. • Pulmonary vascular resistance elevated. • Pulmonary hypertension • Right ventricular hypertrophy, enlargement. • Systemic venous congestion.

17. Mitral stenosis-Classification s √

18. Mitral Stenosis Clinical Presentations • Asymptomatic • symptomatic • Dyspnea, PND, Orthopnea • Hemoptysis– usually pulmonary venous hypertension • -rupture of alveolar capillaries. • -pulmonary infarction. • -ruptured of dilated bronchial veins. • -chronic bronchitis. • Signs of right-sided heart failure: in advanced disease • Atrial fibrillation • Systemic embolization

19. Mitral Stenosis Diagnosis • Clinical • - and P2 (pulmonary hypertension) • Low-pitched mid diastolic rumble • Opening snap(OS)开瓣音and Loud S1 indicating pliable leaflets • short OS-S2 interval indicates severe MS • Mitral facies • other auscultatory signs as per co-existing disease ECG • P mitrale: broad, notched P wave in II and biphasic in V1 • RVH and rightward axis if significant PHT

20. Mitral Stenosis Diagnosis • CXR - LAA and LA enlargement • increased upper lobe vascularity • Kerley B and A lines • dilated PA • MV calcification • ECHO: The GOLD STANDARD for diagnosis. Asses mitral valve mobility, gradient and mitral valve area

21. MS echo

22. Mitral stenosis- complications • Atrial fibrillation/flutter. • Embolism: Systemic:cerebral, coronary, preipheral; • Acute pulmonary edema. • RV heart failure. • Infective endocarditis. • pulmonary infection.

23. Mitral Stenosis Management Principles • Asymptomatic • no specific therapy • endocarditis prophylaxis • if appropriate, rheumatic fever prophylaxis • Mild and Mod MS ( MVA > 1.5 sq cm and 1.0 to 1.4 sq cm) • Normal physical activity • No specific therapy, restoration of NSR in case of AFib • restoration of NSR and anticoagulation in case of Afib • intervention if PASP > 60 mm of Hg or exertional symptoms

24. Simultaneous LV and LA pressure tracing

25. Mitral Stenosis Management Principles • Severe MS • is usually symptomatic • Percutaneous mitral commissurotomy (PMC) is the treatment • modality of choice in the vast majority • PMC in optimal anatomy has acturial survival rate of 95% • after 7 years • PMC in skilled centers has a mortality of < 1% • Success of PMC depends on the pre-PMC valve anatomy • Commissural calcification is a predictor of suboptimal outcome • Complications: severe MR, embolization and cardiac perforation

26. Mitral Stenosis Management Principles • Surgical treatment • commissurotomy (only occasionally indicated, usually PMC) • valve replacement

28. √

29. Aortic Stenosis

30. Aortic Stenosis Etiology • Most common surgical valve disease in the developed world • Degenerative/calcification • - most common cause in the industrialized world • under 70 years of age ~ 70 % bicuspid and ~ 15 % tricuspid • over 70 years of age, >50 % tricuspid and ~ 25 % bicuspid • Rheumatic • most common cause in the developing world • almost always associated with MV disease • Other • associated with other congenital cardiac abnormalities • (Co-arctation, VSD, Hypoplastic left heart, etc.,,)

34. Pathophysiology of Aortic Stenosis • A pressure gradient develops between the left ventricle and the aorta. (increased afterload) • LV function initially maintained by compensatory pressure hypertrophy • When compensatory mechanisms exhausted, LV function declines.

35. Pathophysiology of aortic stenosis Aortic stenosis LV outflow obstruction LV systolic pressure Aortic pressure LV hypertrophy LV dysfunction Myocardial ischaemia LV failure

36. Aortic Stenosis Overview: • Normal Aortic Valve Area: 3-4 cm2 • Symptoms: Occur when valve area is 1/4th of normal area. • Types: • Supravalvular • Subvalvular • Valvular

37. Aortic Stenosis Diagnosis • Clinical • pulsus parvus et tardus细迟脉 (absent in hypertensives and elderly) • Reduced systolic and pulse pressure • systolic thrill and typical heaving apical impulse • S4 and late peaking ejection systolic murmur • paradoxical split of 2nd HS in severe AS • other auscultatory signs modified by co-existing disease • Syncope: (exertional) • Angina: (increased myocardial oxygen demand; demand/supply mismatch) • Dyspnea: on exertion due to heart failure (systolic and diastolic) • Sudden death

38. Aortic Stenosis Diagnosis • ECG • LVH with strain, conduction abnormalities • CXR • dilated ascending aorta (post-stenotic dilatation) • Valve calcification

39. Aortic Stenosis Diagnosis • Echo (primary diagnostic modality) • - AV anatomy (tricuspid, bicuspid, calcification) • Mild Vs. Moderate Vs. Severe AS • AVA and gradients can be calculated • progression of disease can be monitored • assessment of LV function and coexisting lesions • Cath • ususally done to assess coronaries prior to valve surgery • helpful to assess severity in complex situations

40. Evaluation of AS 常以左心室－主动脉收缩期压差判断狭窄程度，平均压差>50mmHg或峰压差≥70mmHg为重度狭窄 Cardiac catheterization: Should only be done for a direct measurement if symptom severity and echo severity don’t match OR prior to replacement when replacement is planned.

41. Aortic Stenosis Management Principles • Asymptomatic • no specific therapy • endocarditis prophylaxis • if appropriate, rheumatic fever prophylaxis • Mild and Mod AS ( AVA > 1.5 sq cm and 1.0 to 1.4 sq cm) • Normal physical activity • No specific therapy, restoration of NSR in case of AFib • approx. progression is a decrease by 0.1 sq cm per year • annual echo follow-up

43. Aortic Stenosis Management Principles • General- IE prophylaxis in dental procedures with a prosthetic AV or history of endocarditis. • Medical - limited role since AS is a mechanical problem. Vasodilators are relatively contraindicated in severe AS • Aortic Balloon Valvotomy- shows little benefit. • Surgical Replacement: Definitive treatment

44. Aortic Stenosis Management Principles • Severe AS • usually symptomatic within 2 years • asymptomatic severe AS : no surgery • asymptomatic severe AS: exercise symptoms=?surgery • symptomatic severe AS: surgery • symptomatic severe AS if not operated has an average life • expectancy of 2 to 3 years • severe AS with HF has mortality of nearly 100% • in 1 to 2 years if not operated

47. Management Strategy for Patients With Severe Aortic Stenosis Bonow, R. O. et al. J Am Coll Cardiol 2008;52:e1-e142

48. Mitral Regurgitation

49. Acute MR Etiology • Endocarditis • Acute MI • Malfunction or disruption of prosthetic valve

50. Management of Acute MR • Myocardial infarction: Cardiac cath or thrombolytics • Most other cases of mitral regurgitation is afterload reduction: • Diuretics and nitrates • nitroprusside, even in the setting of a normal blood pressure.