浙江大学医学院：二尖瓣及主动脉瓣疾病的诊断与治疗（张芙荣）

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

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

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

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

Superior Vena Cava Aorta Pulmonary Arte ry Pulmonary Ve in Left Right trium Atrium Mitral Vale Pulmonary Left Aortic Valve Ventricle Valve TricuspI Ventricl Valve Inferior Vena Cava

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: Table 3 Etiology of single native left- sided valve disease Aortic stenosis n=1197 Aortic regurgitation n=369 Mitral stenosis n=336 Mitral regurgitation n=877 Degenerative(%) 81.9 12.5 613 Rheumatic(%) 11. 2 15.2 854 14.2 Endocarditis(%) 0.8 7.5 0.6 3.5 Inflammatory(%) 0.1 0.8 〔 ongenital154 15.2 0.6 4.8 Ischaemic (%) Other(%) 77 09 8.1 Bernard lunga*, 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

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

总论 病人评估: 诊断 严重程度评估 预后评估 干预指征

总 论 病人评估： 诊断 ↓ 严重程度评估 ↓ 预后评估 ↓ 干预指征

Strategy for Evaluating Heart Murmurs Cardiac murmur Systolic Murmur Diastolic Murmur Continuous Murmur MidsystoliC, Early systolic grade 2 or Midsystolic, less(see text) grade 3 or more Late systolic Holosystolic Echocardiography Asymptomatic and Symptomatic or Venous hum no associated other signs of Catheterization Mammary souffle findings cardiac disease and angiography if appropriate of pregnancy No further workup BonowRo. et al. J Am Coll cardiol 2008: 52: e1-e142

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

1st 12nd 3rd Atrial Normal ITIlTU Aortic stenosis Mitral regurgitation Aortic regurgitation E m Mitral stenosis F MwwiwwwwwwwwwwwwwwwwwwiwwwM Patent ductus arter。sus Diastole I Systole Diastole Systole Phonocardiograms from normal and abnormal heart sounds

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

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

临床评估 症状分析 体征:杂音 超声心动图 KEY TO DIAGNOS|S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

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

临床评估 X线→钙化评估 放射核素造影→窦律下E值评估(返流性ⅦHD) 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GAD ·MR→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

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