教学讲稿倪超-瓣膜病

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1、ValvularHeartDiseaseNiChao,M.D.DivisionofCardiologyObjectivesTounderstandthepathophysiologyofthemajorVHDsTolearnhowtoexaminethepatientTounderstandtheprinciplesoflaboratorydiagnosisTolearnthefundamentalsfortreatmentofcardiacvalveabnormalitiesMitralStenosisEtiologyAlmostalwaystheresultofrhe

2、umaticfeverLesscommoncausesCongenitalMSSystemiclupuserythematosusRheumatoidarthritisAtrialmyxomaBacterialendocarditis.EpidemiologyRareinindustrializedcountriesinpatients<40Verycommonindevelopingcountries,esp.SouthAsiawithseverediseaseoftenatearlyage(<20)2/3ofallpatientswithMSarefemale.The

3、onsetofsymptomsisusu.betweenthe3rdand4thdecades.PathologyThemitralvalvearea(MVA)isnormally4-6cm2inadultAcuterheumaticfevercausesimmune-medi-atedinflammationofthemitralandothervalvesTheleafletsthickenedandthecommissuresfusedalongwiththickeningandshorteningofthechordaetendineaenarrowingoft

4、hemitralvalveorificePathophysiologyMVAreducedto2cm2:increasedleftatrialpressure(LAP)isnecessaryfornormaltrans-mitralflowMVAreducedto1cm2:aLAPof25mmHgisrequiredarisein:Pulmonaryvenouspreesure(PVP)Pulmonarycapillarywedgepressure(PCWP)exertionaldyspneaPathophysiologyProgressivedilationofth

5、eLApredisposesmuralthrombiandatrialfibrillationChronicelevationofLAPpulmonaryhypertension,tricuspidandpulmonaryre-gurgitationrightheartfailurePathophysiologyPatientsathighriskareofmuralthrombiover35yearsoldatrialfibrillationwithalowcardiacoutput(CO)havingalargeleftatrialappendage.Atrial

6、fibrillationinupto40%ofpatientsdecreasesCOby20%.ClinicalManifestationsHistoriesofrheumaticfever,murmurDyspneaPalpitationsChestpainHemoptysisEdemaThromboembolismPhysicalExaminationLow-pitcheddiastolicrumbleOpeningsnapS1,atrialfibrillation,P2RVheaveElevatedneckveins,hepatomegaly,ascites,p

7、edaledemaCoexistentmurmursThromboemboliceventsChestX-RayLeftatrialenlargementPulmonaryedemaProminenceofpulmonaryarteriesEnlargementofrightventricleEKGLeft,rightatrialabnormalitiesatrialfibrillationRightVenticularhypertrophyEchocardiogramEnlargedLAMarkedlythickened,o