VALVULAR HEART DISEASE

1. VALVULAR HEART DISEASE Shen Jieyan MD SSMU Department of cardiology

2. Rheumatic Fever • Definition: autoimmune disease caused by streptococcal infection, cross-react between streptococcal antigens and structural glycoprotein of heart, joints, central nerves system and connective tissue. • Pathology: exuduation, proliferation (Aschoff nodes), scarring

3. Rheumatic Fever • Clinical Manifestations: fever, rheumatic carditis, arthritis, chorea, deformity of skin • Laboratory finding: ASO>500U, ASK>80U, ESR↑,Alb↓,γ+a2↑ CRP(+), CPK-MB↑, GOT↑,TnT TnI↑, C3↑, IgA↑

4. Rheumatic Fever • Diagnosis: Jones standards, 1992 AHA • Treatment: 1) rest 2) antibiotics :Penicillin 3) anti- inflammation: Aspirin Corticosteroids 4) others • Prevention

5. Mitral Stenosis • Etiology: predominant cause: rheumatic fever rare cause • Pathology: thickening, shortening, adhering, calcium depositing, and scarring four forms of fusion: (1) commissural, (2) cuspal, (3)chordal, (4)combined two types of shape: fish-mouth shaped, funnel-shaped

6. Mitral Stenosis • Pathophysiology: normal cross-sectional area:4-6 cm2 mild MS: <2 cm2, LAP↑→LAH ---compensated period moderate MS: <1.5 cm2, PVP↑, PCWP↑, →interstitial edema severe MS: <1.0 cm2,PAP↑→RVoverload →RV failure →TR →PR

8. Mitral Stenosis • Clinical Manifestations (MVA<1.5cm2) 1. Symptom: dyspnea, hemoptysis, cough, hoarseness (ortner’s syndrome) 2. Signs: -Mitral faces -Diastolic thrill at apex -S1↑(flexible), OS, Diastolic rumbling murmur at apex, -P2↑, splitting, Graham-Steel murmur(PR),TR

9. Mitral Stenosis • Laboratory Examination - ECG: 1) left atrial enlargement: P wave (II,V1) 2) Af; 3) right ventricular hypertrophy - X-film: change in cardiac silhouette, Kerley B lines - Echocardiography: M-mode, Two- dimensional, Doppler

11. 正常二尖瓣形态

12. 风湿性二尖瓣狭窄Rheumatic mitral stenosis

13. 风湿性二尖瓣狭窄Rheumatic mitral stenosis

14. 风湿性二尖瓣狭窄Rheumatic mitral stenosis

15. 风湿性二尖瓣狭窄Rheumatic mitral stenosis

16. 风湿性二尖瓣狭窄Rheumatic mitral stenosis

17. Mitral Stenosis • Diagnosis & Differential diagnosis - Diastolic rumbling murmur at apex + X-film + ECG + Echo - relative MS; Austin-Flint murmur; left atrial myxoma ; Graham steell murmur • Complication: Atrial fibrillation; acute pulmonary edema; congestive heart failure; thromboembolism; infective endocarditis; pulmonary infective

18. Mitral Stenosis • Management: - Medical treatment: Antibiotics, Diuretics and Digitalis, Antiarrhythmic drugs, Anticoagulant - Percutaneous balloon mitral valvuloplasty ( PBMV) - Surgical treatment: Closed mitral valvotomy Open valvotomy Mitral valve replacement

19. Mitral Regurgitation • Etiology and Pathology - Abnormalities of valve leaflets: Rheumatic, infective - Abnormalities of the mitral annulus: dilatation, calcification - Abnormalities of the chordae tendineae: congenitally, infective, trauma, Rheumatic - Involvement of papillary muscle: CAD

20. Mitral Regurgitation • Pathophysiology In systolic period, blood flow from LV → LA, LA filling pressure↑; in diastolic period, LV accepts more blood →LV dilation, hypertrophy →LVEDP↑ →LAP↑→PCWP↑→PAP↑→RHF; CO↓ • Chronic • Acute

22. Mitral Regurgitation • Clinical Manifestations (1) Symptoms: asymptomatic( gradually,>20 years), palpitation, fatigue, dyspnea, pulmonary edema (2) Signs: - apical pulse→left,lower - apical beat heavy - cardiac dullness enlarged→left - pansystolic murmur at apex, radiate to left axilla, subscapular - S1↓,P2↑

23. Mitral Regurgitation • Laboratory Examination: - ECG: LA enlargement, Af, LV hypertrophy - X- Film: chronic– cardiomegaly (LV, LA) acute– interstitial edema (Kerley B) - Echocardiography: two-dimensional, Doppler , color flow mapping - Angiocardiography & Magnetic resonance imaging

24. 二尖瓣脱垂伴关闭不全

25. 二尖瓣关闭不全

26. Mitral Regurgitation • Diagnosis: systolic murmur at apex + LA↑, LV↑+ Echo • Differential Diagnosis: relative MR, ventricular septal defect, tricuspid regurgitation, aortic stenosis • Management: - Medical treatment - Surgical treatment

27. Aortic Stenosis • Etiology & Pathology: - Rheumatic AS, Congenital AS, Degenerative calcific AS • Pathophysiology: - Obstruction to LVOT→ LVH→ LAH→ PVP↑→ Pulmonary edema; - LVEF↓→ischemia of peripheral、brain、heart

29. Aortic Stenosis • Clinical Manifestations: - Symptoms: heart failure (fatigue, dyspnea), angina pectoris, syncope, sudden death - Signs: Apical impulse↑,to left Systolic thrill in AV area,pulse↓ Cardiac dullness→left Ejection sound & SM in AV area, radiate to neck A2↓ splitting paradoxically

30. Aortic Stenosis • Laboratory Examination: ECG; X- film; Echocardiography; Angiography • Diagnosis & Differential Diagnosis: - murmur + Echo - MI, TI, VSD - other murmurs of LVOT obstruction

31. 风湿性主动脉瓣狭窄伴返流 Rheumatic aortic stenosis and regurgitation

32. 风湿性主动脉瓣狭窄伴返流 Rheumatic aortic stenosis and regurgitation

33. 风湿性主动脉瓣狭窄伴返流 Rheumatic aortic stenosis and regurgitation

34. 风湿性主动脉瓣狭窄伴返流 Rheumatic aortic stenosis and regurgitation

35. Aortic Stenosis • Complications: Sudden death, heart failure, arrhythmia, infective endocarditis, systemic embolism • Management: - Medical treatment - Surgical treatment

36. Aortic Regurgitation • Etiology & Pathology - Valvular Disease: rheumatic, congenital, infective prolapse, ankylosing spondylitis, degenerative - Aortic Root Disease: syphilitic aoritis, Marfan syndrome, ankylosing spondylitis, degenerative - Acute AR: infective, trauma, aortic dissection

37. Aortic Regurgitation • Pathophysiology: - LV receives both blood from LA & AO →volume overload →LV dilation → pulmonary edema →relative MI,MS; - Diastolic pressure↓,pulse pressure↑

39. Aortic Regurgitation • Clinical Manifestations: - Symptom: palpitation, angina - Sign: apical impulse→ left, inferior cardiac dullness →left, inferior Boot-shaped shadow—cardiac waist↓ DM in AV2 area →apex S1↓,A2↓ relative MI—SM at apex relative MS—Austin Flint

40. Aortic Regurgitation • Sign: Peripheral vascular sign: - pulse pressure↑, carotid pulsation↑ - Musset sign, water hammer pulse, Traube sign, Duroziez murmur, Muller sign, Quincke sign, • Laboratory Examination: ECG, X-Film, Echo, etc

42. Aortic Regurgitation • Diagnosis & Differential Diagnosis: AI + peripheral vascular signs + Echo • Complication: infective endocarditis ventricular arrthymia heart failure

43. Aortic Regurgitation • Management: Medical treatment Surgical treatment