扬州大学：《外科学》课程教学课件（PPT讲稿，Surgery）Chapter 21. Heart Diseases_Valvular Diseases

ValvularDisease

Valvular Disease

Objectives: To understand the pathophysiology: To learn how to examine the patient. To understand the principles of laboratorydiagnosis: To learn the fundamentals for treatment

Objectives • To understand the pathophysiology • To learn how to examine the patient • To understand the principles of laboratory diagnosis • To learn the fundamentals for treatment

1. Mitral Stenosis

1. Mitral Stenosis

Etiology Almost always the result of rheumatic fever: Less common causes- Congenital mitral stenosis-Systemic lupus erythematosus- Rheumatoid arthritis- Atrial myxoma- Bacterial endocarditis

Etiology • Almost always the result of rheumatic fever • Less common causes – Congenital mitral stenosis – Systemic lupus erythematosus – Rheumatoid arthritis – Atrial myxoma – Bacterial endocarditis

Epidemiology: Rare in developed countries in patients <40. Very common in developing countries, espSouth Asia, often at early age (<20): 2/3 of all patients are female.. The onset of symptoms usu.thebetween3rd and 4th decades

Epidemiology • Rare in developed countries in patients <40 • Very common in developing countries, esp. South Asia, often at early age (<20) • 2/3 of all patients are female. • The onset of symptoms usu. between the 3rd and 4th decades

Pathology: Normal mitral valve area (MVA): 4-6 cmAcute rheumatic feverImmune-mediated inflammation of valves- the leaflets thickened- the commissures fused- thickening and shortening of chordae tendineae: Narrowing of mitral valve orifice

Pathology • Normal mitral valve area (MVA): 4-6 cm2 • Acute rheumatic fever • Immune-mediated inflammation of valves – the leaflets thickened – the commissures fused – thickening and shortening of chordae tendineae • Narrowing of mitral valve orifice

Pathophysiology: MVA 2 cm?: increased left atrialpressure(LAP) is necessaryfor normaltransmitralflow MVA 1cm?: LAP 25 mm Hg required→PVP and PCWP↑→>exertional dyspnea: ChronicelevationofLAP-→>pulmonaryandtricuspidpulmonaryhypertension,regurgitation → right heart failure

Pathophysiology • MVA 2 cm2 : increased left atrial pressure (LAP) is necessary for normal transmitral flow • MVA 1cm2 : LAP 25 mm Hg required→ PVP and PCWP→exertional dyspnea • Chronic elevation of LAP→pulmonary hypertension, tricuspid and pulmonary regurgitation → right heart failure

: Progressive dilation of the LA predisposes:- Mural thrombi: embolize in 20% of patientsPatients at high risk.over35years old: Atrial fibrillation with a low cardiac outpu: large LA appendage- Atrial fibrillation:in up to 40% of patients decreases cardiac output by 20%

• Progressive dilation of the LA predisposes: – Mural thrombi: embolize in 20% of patients Patients at high risk: • over 35 years old • Atrial fibrillation with a low cardiac output • large LA appendage. – Atrial fibrillation: • in up to 40% of patients • decreases cardiac output by 20%

Clinical Manifestations. Histories of rheumatic fever, murmur·Dyspnea: Palpitations· Chest pain: Hemoptysis: a late finding·Edema: Thromboembolism: may be 1st symptom

Clinical Manifestations • Histories of rheumatic fever, murmur • Dyspnea • Palpitations • Chest pain • Hemoptysis: a late finding • Edema • Thromboembolism: may be 1st symptom

Physical Exam? Low-pitched diastolicrumbleOpening snapS, T, Atrial fibrillation, P,Coexistent murmurs. RV heave: Elevated neck veins, hepatomegaly, ascitespedal edemaThromboembolic events

Physical Exam • Low-pitched diastolic rumble • Opening snap • S1, Atrial fibrillation, P2  • Coexistent murmurs • RV heave • Elevated neck veins, hepatomegaly, ascites, pedal edema • Thromboembolic events