从风湿性心脏病致心力衰竭的病例看心肌重构课件

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1、从风湿性心脏病致心力衰竭的病例看心肌重构褚祎、姜岚、王晶、夏雪、曹洁CompensatoryMechanismstoHeartFailure1.NeurohumoralActivation2.FunctionalAdjustment3.StructuralAdaptation4.ExtracardialCompensationNeurohumoralActivation(1)ActivationofSympatheticNervousSystem(2)ActivationofRenin-AngiotensinSystemFunctionalAdjustmen

2、t(1)IncreasedHeartRate(2)IncreasedPreload(3)IncreasedContractilityStructuralAdaptation(1)MyocyteRemodelinga.MyocardialHypertrophyConcentricHypertrophyEccentricHypertrophyb.ChangesinMyocytePhenotype(2)ChangesinNon-MyocytesExtracardialCompensation(1)RedistributionofBloodFlow(2)Increas

3、einRedCells(3)IncreaseAbilityofCellstoUseOxygen病例病史：患者31年前于重体力劳动后出现心悸、喘憋，伴夜间憋醒，需坐起。诊断“风湿性心脏病”。其后间断出现喘憋，多于感冒后发生，发作时轻微活动即可发生喘憋，伴夜间不能平卧。后来发现二尖瓣狭窄，心房颤动，心力衰竭。近2年来，患者运动明显受限，经常喘憋，夜间坐位入睡。3天来，受凉后喘憋加重，不能自行行走，夜间坐位入睡，伴咳血痰，暗红色为主，偶有鲜红色血痰。自发病来，精神、睡眠差，食欲不佳，小便次数增多，尤其夜尿增多，6~7次/夜，大便如常。查体：BP：160/90mmHg

4、，P：64次/分，口唇略发绀，双肺可闻及满肺哮鸣音及少量细湿罗音。心尖搏动弥散，位于第Ⅴ肋间腋中线上。心尖部触及震颤。叩诊心界扩大。心律不齐，S1强弱不等，A2=P2，心尖部可闻及III级收缩期杂音，舒张期隆隆样杂音。腹部膨隆，腹软，无压痛，肝脾触诊不满意，双下肢轻度可凹性水肿。Rheumaticheartdisease:Mitralverrucousendocarditis----thickeningofvalvesandchordaetendineaValveImpairmentandCompensationMitralstenosis:fibrosisa

5、ndthickeningofvalves,shorteningofchordaetendineaCompensation:elevatedtransmitralpressureLApressurePVpressurecongestionoflungDyspneaLVcontractionPalpitationFromfunctionalcompensationtoconstructionalcompensationsmallergapVenouspulmonaryhypertensionPulmonaryarteryhypertensionIncreased

6、RVpostloadHeartremodelingDamagetomyocardialcellImpairedsystolicanddiastolicfunctionImpairedcomplianceRightheartfailureCongestionofsystemiccirculationAnorexy,Ascites,ExtremitasinferioredemaIncreasedLVpostloadLVfailurecongestionoflungInfernalcircleHEARTFAILUREMyocardialremodelingCellu

7、larhypertrophyCollagen:amount,phenotype,cross-linking.Celldeath:apoptosis,necrosiscross-sectionalareaanddiameterbalancedincreaselengththanthickcentrichypertrophyeccentrichypertrophyInthetransitiontofailureincreasingwallthicknesspumpfunctionoverallwallthicknessandLVvolumemyocardialco

8、mpliancediastolicpr