慢性二狭
左房增大及钙化，房颤时血栓形成
18
二尖瓣狭窄
• 病理解剖与/或瓣膜本身增厚
但瓣膜尚有一定的弹性
能自由活动
漏斗型：瓣膜极度增厚
腱索、乳头肌粘连缩短
瓣膜活动显著受限
瓣口呈“鱼口”状，常伴1二9
二尖瓣狭窄
• 病理解剖与病理生理
正常：4-6cm2 轻度：>1.5cm2 中度: 1～1.5 cm2 重度: <1 cm2
左室充盈减慢
MS
二尖瓣狭窄
22
二狭病理生理
左房压力
三 部 肺循环压力 曲
右心室压力
Valvular Heart Disease
心脏瓣膜病
1
目的要求
❖掌握
➢常见瓣膜病变病理解剖 ➢病理生理、临床表现、诊断方法
❖熟悉
➢心脏瓣膜病治疗原则
2
心脏血流动力学示意图
3
Normal
MS
4
Normal
MS
5
6
General Consideration
以下因素
Inflammation 炎症
最常受累为二尖瓣，其次为主动脉瓣
10
Mitral Valve Disease
Classification
Mitral stenosis
Mitral incompetence
11
Part I
Mitral stenosis
12
Mitral Stenosis Natural History
Progressive, life long disease
Right heart failure
21
Pathophysiological progression of mitral stenosis
Right heart failure
RV enlargement
右心衰 右室增大
pulmonary arterial pressure elevation
肺动脉压力增高
8
风湿热 acute articular rheumatism
• 全身结缔组织免疫性疾病 • 乙型A族溶血性链球菌 • 主要表现：
– 心脏炎 – 游走性关节炎 – 皮肤环形红斑 – 皮下结节 – 舞蹈病
9
Brief introduction
Bicuspid valve which was followed by aortic valve was viewed as the most susceptive one to rheumatic fever
呈进展性病程，往往伴随终生
Usually slow & stable in the early years
早期进展较缓慢且稳定
Progressive acceleration in the later years
晚期病情加速恶化 13
Mitral Stenosis Natural History
several years latency fever to symptom onset
20
Mitral Stenosis: Pathophysiology
Almost asymptomatic
Mild Stenosis (>1.5cm2)
Moderate Stenosis
(1-1.5cm2)
Left atrial pressure
Normal valve area: 4-6 cm2
Degeneration 退化
deformation畸形
Ischemic necrosis 缺血坏死
Trauma 创伤
以下瓣膜结构 改变
Leaflet 瓣叶
valve ring瓣环 Chordae tendineae
腱索 papillary muscle 乳头肌
瓣膜狭窄
&
瓣膜关闭 不全
7
心脏瓣膜病病因
多数成年患者：二狭由风湿热引起
2/3 of patients with MS are female and 1/2of all without history of rheumatic fever
2/3是女性，1/2无风湿热病史
15
16
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Mitral Stenosis: Etiology & pathology
Pathological change is inflammation and thickening of leaflet tips that restricts the motion of the tips
病理改变：炎症及瓣叶增厚粘连限制瓣膜活动
Chronic MS LAE & calcification， LA embolization especially accompanied with AF
❖风湿性心脏病(风心病、rheumatic heart disease) ➢风湿性炎症过程所致的瓣膜损害 ➢主要累及40岁以下人群 ➢我国常见的心脏病之一
❖ 瓣膜粘液样变性和老年人瓣膜钙化日益↑
VHD comprises a variety of etiologies involving but most cases of it were at one time due to rheumatic heart disease
pulmonary venous pressure
肺静脉压力增高
pulmonary capillary pressure elevation
肺毛细血管压力增高
pulmonary venous congestion
肺静脉淤血
LAE LA pressure elevation
左房增大 左房压力增高
Slowing LV fulfillment
感染潜伏多年后出现症状
Additional 10 years before disabling symptoms
出现症状后10年内可丧失生活能力
14
Mitral Stenosis: Etiology & pathology
Most adult patients: MS is the result of rheumatic fever
maintain normal flow across the valve
maintain normal cardiac output
shorten diastole
& increase mitral flow
rate
(<1cm2)
Severe Stenosis
severe pulmonary venous congestion