Valvular Heart Disease

1. Valvular Heart Disease Dr. Hu Gangying Department of Cardiology Renmin Hospital of Wuhan University

2. 目的要求 • 掌握 • 常见瓣膜病变病理解剖 • 病理生理、临床表现、诊断方法 • 熟悉 • 心脏瓣膜病治疗原则

3. Definition VHD 心脏瓣膜病是由于炎症、粘液样变性、退行性改变、先天性畸形、缺血性坏死、创伤等原因引起的单个或多个瓣膜结构（瓣叶、瓣环、腱索或乳头肌）的功能或结构异常，导致瓣口狭窄和/或关闭不全。

4. General Consideration 以下因素 以下瓣膜结构改变 瓣膜狭窄 Inflammation Degeneration Leaflet deformation畸形 & valve ring Ischemic 瓣膜关闭不全 papillary muscle 乳头肌 necrosis 坏死 Trauma

5. Brief introduction Bicuspid valve which was followed by aortic valvewas viewed as the most susceptive one to rheumatic fever 最常受累为二尖瓣，其次为主动脉瓣

6. 心脏瓣膜病病因 • 风湿性心脏病(风心病、rheumatic heart disease) • 风湿性炎症过程所致的瓣膜损害 • 主要累及40岁以下人群 • 我国常见的心脏病之一 • 瓣膜粘液样变性和老年人瓣膜钙化日益↑ VHD comprises a variety of etiologies involving but most cases of it were at one time due to rheumatic heart disease

7. Normal MS

8. Normal MS

9. Mitral Valve Disease Classification Mitral stenosis Mitral incompetence

10. Part I Mitral stenosis

11. Mitral StenosisNatural History Progressive, life longdisease 呈进展性病程，往往伴随终生 Usually slow & stable in the early years 早期进展较缓慢且稳定 Progressive acceleration in the later years 晚期病情加速恶化

12. Mitral StenosisNatural History several years latency fever to symptom onset 感染潜伏多年后出现症状 Additional 10 years before disabling symptoms 出现症状后10年内可丧失生活能力

13. Mitral Stenosis: Etiology & pathology Most adult patients: MS is the result of rheumatic fever 多数成年患者：二狭由风湿热引起 2/3 of patients with MS are female and 1/2of all without history of rheumatic fever 2/3是女性，1/2无风湿热病史

14. Chronic MS LAE & calcification， LA embolization especially accompanied with AF Mitral Stenosis: Etiology & pathology Pathological change is inflammation and thickening of leaflet tips that restricts the motion of the tips 病理改变：炎症及瓣叶增厚粘连限制瓣膜活动 慢性二狭 左房增大及钙化，房颤时血栓形成

15. (1-1.5cm2) Mitral Stenosis: Pathophysiology Normal valve area: 4-6 cm2 Mild Stenosis Almost asymptomatic (>1.5cm2) shorten diastole maintain normal flow across the valve Left atrial pressure & Moderate Stenosis increase mitral flow rate maintain normal cardiac output Right heart failure (<1cm2) Severe Stenosis severe pulmonary venous congestion

16. Pathophysiological progression of mitral stenosis Right heart failure 右心衰 右室增大 RV enlargement pulmonary arterial pressure elevation 肺动脉压力增高 pulmonary venous pressure 肺静脉压力增高 pulmonary capillary pressure elevation 肺毛细血管压力增高 pulmonary venous congestion 肺静脉淤血 LAE 左房增大 LA pressure elevation 左房压力增高 Slowing LV fulfillment 左室充盈减慢 MS 二尖瓣狭窄

17. Normal MS

18. Normal MS

19. Normal MS

20. Clinical manifestation: Symptoms • Manifested after moderate stenosis • 中度狭窄方出现症状 • Often precipitated by AF or pregnancy • 房颤或妊娠时症状加重 • Shortness of breath on exertion might be the first symptom • 劳累后呼吸困难通常为首发症状

21. (Area of mitrial valve ＜1.5 ㎝2) dyspnea -exertion -resting -orthopnea -paroxysmal nocturnal dyspnea Clinical manifestation: Symptoms • （瓣口面积＜1.5㎝2） • 呼吸困难 • 最常见早期症状 • 劳力性 • 静息时、端坐呼吸、阵发 • 性夜间呼吸困难 • 肺水肿

22. Clinical manifestation: Symptoms • Hemoptysis • Massive hemoptysis • Suptum with blood, often with PND or cough • Pink,frothy suptum • Pulmonary embolism with hemoptysis • Cough • Hoarseness • 咯血 • 咯大量鲜血 • 痰中带血（夜间阵发性呼吸困难） • 粉红色泡沫痰 • 肺栓塞伴咯血 • 咳嗽 • 声嘶

23. Mitral facies in severe MS 重度MS常有 “ 二尖瓣面容 ” 双颧绀红 Clinical manifestation: Signs

24. Clinical manifestation: Signs • Sign of MS • S1 is accentuated S1亢进 • OS after aortic valve closure 主动脉关闭后开瓣音 • Low pitch diastolic murmurs at the apex心尖区低调舒张期杂音 • 隆隆样或滚筒样，舒张中晚期，递减-递增型，伴舒张期震颤 • In severe MS with low flow- S1, OS & rumble may be inaudible重度二狭时S1减弱、开瓣音消失 S1 S2 OS S1

25. Clinical manifestation: Signs • Pulmonary hypertension & RVE • Dispersion of beat at apex • RV lift • P2 loudness and split • Graham Steell murmur • relative TI with RVE • 肺动脉高压及右室 • 扩大 • 心尖搏动弥散 • 右室抬举感 • P2亢进及分裂 • Graham Steell 杂音:相对性肺闭，舒张期 • 杂音 • 相对性三闭伴右室大

26. Mitral Stenosis: Laboratory Examination X-ray • 左房大 • 右室增大 • 主动脉结小 • 肺动脉段突

27. “二尖瓣型P波”,P波宽度>0.12S PV1终末负性向量增大 QRS波群示电轴右偏和 RVH Mitral Stenosis: Laboratory Examination ECG

28. Mitral Stenosis: Laboratory Examination Echocardiography Echo-Doppler confirm diagnosis & estimate severity 超声可以确诊及评估严重程度 Doppler echocardiography M-mode echocardiography

31. The orifice of the stenotic MV can be visualized and. measured mitral valve area is approximately 1.1 cm2 可见狭窄的瓣膜孔，经测定为1.1 cm2

32. Colorful ejection flow at mitral vavle during diastole Mural thrombosis in LA

33. Mitral Stenosis: Laboratory Examination Cardiac Catheterization Catheterization provides assessment of regurgitation, LV function and PAP for determining whether valvotomy is indicated 导管用于术前评估左室功能及肺动脉压

34. Mitral Stenosis: Laboratory Examination Cardiac Catheterization It is recommended for the patients who have a discrepancy between clinical and echocardiographic findings 用于临床表现与超声结果不符时

35. MS: Diagnosis • Low pitch DM at the apex • 心尖区低调舒张期杂音 • X-ray, ECG : LAE • 胸片、心电图示左房大 • UCG: final diagnosis • 超声：确诊 • DM might be lowered or disappeared if AF • 房颤时舒张期杂音减弱甚至消失

36. Differential diagnosis Low pitch DM at the apex • Blood flow through MV increase: severe MI 、massive left to right congenital heart disease (eg. VSD、PDA)、hyperkinesis circulation (hyperthyroidism and anemia) • Austin-Flint murmur ：caused by severe AI • mucous tumor in LA：

37. Mitral Stenosis: Complications • Atrial fibrillation • Acute pulmonary edema • Systemic embolization • Right heart failure • Endocarditis • Pulmonary infections • 房颤:早期 • 急性肺水肿:严重MS • 血栓栓塞 • 右心衰竭:晚期 • 感染性心内膜炎:少见 • 肺部感染:常见

38. Mitral Stenosis: Therapy • General treatmentAvoiding from factors cause cardiac overload as follow： Infection、anemia 、 salty diet、exhausting • Medical • Treat rheumatic activity • Diuretics 利尿剂 • Endocarditis prophylaxis 预防感染性心内膜炎

39. Mitral Stenosis: Therapy 并发症的处理 1 大量咯血：镇静、利尿 2 急性肺水肿：处理原则同急性左心衰 避免使用扩动脉药，选用硝酸酯类药 正性肌力药对MS的肺水肿无益 3 房颤 4 预防栓塞 5 右心衰竭：限钠、利尿

40. Mitral Stenosis:Therapy • Balloon valvuloplasty 球囊扩张术 • Effective long term improvement • 能长期改善症状 • Surgical • Mitral commissurotomy 瓣膜分离术 • Mitral Valve Replacement 瓣膜置换术

41. Asympotomic: 84% Mild sympotom: 42% Moderate & severe sympotom: 15% Heart failure: 62% Embolism: 22% Infectious endocarditis : 8% Mitral Stenosis: Prognosis Average duration from occurrence of symptoms to entire disable 7.3 Years 10 yearssurvival rate Reason for death

42. Part II Mitral Incompetence

43. Mitral incompetenceEtiology & pathology • 瓣叶 • 风湿 • 粘液样变 • 心内膜炎 • 肥厚型心肌病 • 先天性 • 瓣环 • 左室增大或伴左心衰 • 退行性变 • 钙化 • Valvular-leaflets • Rheumatic • Myxomatous MV • IE • HCM • Congenital • Annulus • LVE or left heart failure • Degenerative • Calcification

44. Mitral incompetenceEtiology & pathology • 腱索 • 先天性 • 获得性 • 乳头肌 • 缺血 • 坏死 • 外伤 • Chordae • Congenital • Acquaired • Papillary Muscles • Ichemia • Necrosis • Trauma

46. Mitral Incompetence: Pathophysiology Text Text Chronic Mitral Incompetence Acute Mitral Incompetence Text Sorting by rapidity

47. A B C Acute Back flow from LV & PV rush into LA LA & LV volume overload pressure Pulmonary congestion, edema D D Pulmonary hypertension, RHF

48. Right heart failure Backflow Pulmonary hypertension LAE Chronic Chronic LV volume overload Chronic left heart failure Compensatory LVDEV Decompensation (increased LV wall tension) Pulmonary congestion

49. Chronic Mitral incompetence: Pathophysiology 慢性容量负荷代偿LV舒张末期容量 代偿性离心性肥大 LV收缩期部分血排入LA 扩大LA、LV适应容量负荷 舒张末压不致明显 代偿期CO，超正常 不出现肺淤血 持久负荷，引起左心衰，CO 左房压和左心室舒张末压 PA高压、右心衰竭

50. Mitral incompetenceClinical manifestation Dyspnea &Orthopnea Clinical manifestation also present different feature with various rate of progression Fatigue It is Similar to MS Pulmonary hypertension Hemoptysis Systemic embolization