Download Chronic Mitral Regurgitation

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
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MITRAL STENOSIS
AORTIC STENOSIS
MITRAL REGURGITATION -Acute and Chronic
AORTIC REGURGITATION -Acute and Chronic
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TRICUSPID REGURGITATION
TRICUSPID STENOSIS
PULMONARY STENOSIS
PULMONARY REGURGITATION
• MIXED LESIONS
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
病人评估：
论
诊断
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严重程度评估
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预后评估
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干预指征
Strategy for Evaluating Heart Murmurs
Bonow, R. O. et al. J Am Coll Cardiol 2008;52:e1-e142
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 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
Mitral Stenosis
Mitral Stenosis
Etiology
 Rheumatic (nearly all adult MS)
other etiologies are very rare:
 Degenerative (Mitral valve annular calcification,elderly)
 Congenital (parachute MV), MS+atrial septal defect=Lutembacher
syndrome.
Others: post-inflammatory, metabolic syndromes , Other causes of LV
inflow obstr.,atrial myxoma, LA ball thrombus, cor triatriatum. etc.
MITRAL STENOSIS-Pathology
Fusion of the
comissures, cusps or
chords.
Contracture and
thickening of the cusps.
Shortening and fusion of
the chordae tendinae.
Funnel –shaped orifice.
Posterior
cusp
Mitral
annulus
Anterior
cusp
Chordae
tendinae
Papillary
muscles
Mitral Stenosis Overview
• Definition: Obstruction of LV inflow that
prevents proper filling during diastole
• Normal MV Area: 4-6 cm2
• Transmitral gradients and symptoms begin at
areas less than 2 cm2
• Rheumatic carditis is the predominant cause
• Prevalence and incidence: decreasing due to
a reduction of rheumatic heart disease.
Pathophysiology
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Obstruction between LA and LV.
Pressure gradient.
Elevated LA pressure.
LA pressure increases at elevated HR.
Pulmonary vascular resistance elevated.
Pulmonary hypertension
Right ventricular hypertrophy, enlargement.
Systemic venous congestion.
Mitral stenosis-Classification
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Mitral Stenosis
Clinical Presentations
 Asymptomatic
 symptomatic
Dyspnea, PND, Orthopnea
Hemoptysis – usually pulmonary venous
hypertension
-rupture of alveolar capillaries.
-pulmonary infarction.
-ruptured of dilated bronchial veins.
-chronic bronchitis.
Signs of right-sided heart failure: in advanced
disease
Atrial fibrillation
 Systemic embolization
Mitral Stenosis
Diagnosis
• Clinical
- and P2 (pulmonary hypertension)
- Low-pitched mid diastolic rumble
- Opening snap (OS)开瓣音and Loud S1 indicating pliable
leaflets
- short OS-S2 interval indicates severe MS
-Mitral facies
-other auscultatory signs as per co-existing disease
ECG
- P mitrale: broad, notched P wave in II and biphasic in V1
- RVH and rightward axis if significant PHT
Mitral Stenosis
Diagnosis
• CXR - LAA and LA enlargement
- increased upper lobe vascularity
- Kerley B and A lines
- dilated PA
- MV calcification
•ECHO: The GOLD STANDARD for diagnosis. Asses
mitral valve mobility, gradient and mitral valve area
MS echo
Mitral stenosis- complications
• Atrial fibrillation/flutter.
• Embolism: Systemic:cerebral, coronary,
preipheral;
• Acute pulmonary edema.
• RV heart failure.
• Infective endocarditis.
• pulmonary infection.
Mitral Stenosis
Management Principles
• Asymptomatic
- no specific therapy
- endocarditis prophylaxis
- if appropriate, rheumatic fever prophylaxis
• Mild and Mod MS ( MVA > 1.5 sq cm and 1.0 to 1.4 sq cm)
- Normal physical activity
- No specific therapy, restoration of NSR in case of AFib
- restoration of NSR and anticoagulation in case of Afib
- intervention if PASP > 60 mm of Hg or exertional symptoms
Simultaneous LV and LA pressure tracing
Mitral Stenosis
Management Principles
• Severe MS
- is usually symptomatic
- Percutaneous mitral commissurotomy (PMC) is the treatment
modality of choice in the vast majority
- PMC in optimal anatomy has acturial survival rate of 95%
after 7 years
- PMC in skilled centers has a mortality of < 1%
- Success of PMC depends on the pre-PMC valve anatomy
- Commissural calcification is a predictor of suboptimal outcome
- Complications: severe MR, embolization and cardiac perforation
Mitral Stenosis
Management Principles
• Surgical treatment
- commissurotomy (only occasionally indicated, usually PMC)
- valve replacement
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Aortic Stenosis
Aortic Stenosis
Etiology
• Most common surgical valve disease in the developed world
• Degenerative/calcification
- most common cause in the industrialized world
- under 70 years of age ~ 70 % bicuspid and ~ 15 % tricuspid
- over 70 years of age, >50 % tricuspid and ~ 25 % bicuspid
• Rheumatic
- most common cause in the developing world
- almost always associated with MV disease
• Other
- associated with other congenital cardiac abnormalities
(Co-arctation, VSD, Hypoplastic left heart, etc.,,)
Pathophysiology of Aortic Stenosis
• A pressure gradient develops between the
left ventricle and the aorta. (increased
afterload)
• LV function initially maintained by
compensatory pressure hypertrophy
• When compensatory mechanisms exhausted,
LV function declines.
Pathophysiology of aortic stenosis
Aortic stenosis
LV outflow obstruction
LV systolic pressure
Aortic pressure
LV hypertrophy
LV dysfunction
Myocardial ischaemia
LV failure
Aortic Stenosis Overview:
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Normal Aortic Valve Area: 3-4 cm2
Symptoms: Occur when valve area is 1/4th
of normal area.
• Types:
– Supravalvular
– Subvalvular
– Valvular
Aortic Stenosis
Diagnosis
• Clinical
-pulsus parvus et tardus细迟脉 (absent in hypertensives and elderly)
-Reduced systolic and pulse pressure
- systolic thrill and typical heaving apical impulse
- S4 and late peaking ejection systolic murmur
- paradoxical split of 2nd HS in severe AS
- other auscultatory signs modified by co-existing disease
Syncope: (exertional)
Angina: (increased myocardial oxygen demand; demand/supply mismatch)
Dyspnea: on exertion due to heart failure (systolic and diastolic)
Sudden death
Aortic Stenosis
Diagnosis
•ECG
- LVH with strain, conduction abnormalities
• CXR
- dilated ascending aorta (post-stenotic
dilatation)
- Valve calcification
Aortic Stenosis
Diagnosis
• Echo (primary diagnostic modality)
- AV anatomy (tricuspid, bicuspid, calcification)
- Mild Vs. Moderate Vs. Severe AS
- AVA and gradients can be calculated
- progression of disease can be monitored
- assessment of LV function and coexisting lesions
• Cath
- ususally done to assess coronaries prior to valve surgery
- helpful to assess severity in complex situations
Evaluation of AS
常以左心室－主动脉收缩期压差判断狭窄程度，平均压差
>50mmHg或峰压差≥70mmHg为重度狭窄
Cardiac catheterization: Should only be done for a direct
measurement if symptom severity and echo severity don’t match
OR prior to replacement when replacement is planned.
Aortic Stenosis
Management Principles
• Asymptomatic
- no specific therapy
- endocarditis prophylaxis
- if appropriate, rheumatic fever prophylaxis
• Mild and Mod AS ( AVA > 1.5 sq cm and 1.0 to 1.4 sq cm)
- Normal physical activity
- No specific therapy, restoration of NSR in case of AFib
- approx. progression is a decrease by 0.1 sq cm per year
- annual echo follow-up
Aortic Stenosis
Management Principles
 General- IE prophylaxis in dental procedures with
a prosthetic AV or history of endocarditis.
Medical - limited role since AS is a mechanical
problem. Vasodilators are relatively contraindicated
in severe AS
Aortic Balloon Valvotomy- shows little benefit.
Surgical Replacement: Definitive treatment
Aortic Stenosis
Management Principles
• Severe AS
- usually symptomatic within 2 years
- asymptomatic severe AS : no surgery
- asymptomatic severe AS: exercise symptoms=?surgery
- symptomatic severe AS: surgery
- symptomatic severe AS if not operated has an average life
expectancy of 2 to 3 years
- severe AS with HF has mortality of nearly 100%
in 1 to 2 years if not operated
Management Strategy for Patients With Severe Aortic Stenosis
Bonow, R. O. et al. J Am Coll Cardiol 2008;52:e1-e142
Mitral Regurgitation
Acute MR
Etiology
• Endocarditis
• Acute MI
• Malfunction or disruption of prosthetic
valve
Management of Acute MR
• Myocardial infarction: Cardiac cath or
thrombolytics
• Most other cases of mitral regurgitation is
afterload reduction:
– Diuretics and nitrates
– nitroprusside, even in the setting of a normal
blood pressure.
Treatment of Acute MR
• Balloon Pump
• Nitroprusside even if hypotensive
• Emergent Surgery
Chronic Mitral Regurgitation
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Definition: Backflow of blood from the LV to the
LA during systole
Mild (physiological) MR is seen in 80% of
normal individuals.
Chronic Mitral Regurgitation
Etiology
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Myxomatous degeneration (MVP)
Ischemic MR
Rheumatic heart disease
Infective Endocarditis
Pathophysiology of MR
• Pure Volume Overload
• Compensatory Mechanisms: Left atrial
enlargement, LVH and increased contractility
– Progressive left atrial dilation and right
ventricular dysfunction due to pulmonary
hypertension.
– Progressive left ventricular volume overload
leads to dilation and progressive heart failure.
Chronic Mitral Regurgitation
•Clinical
• Auscultation: soft S1 and a holosystolic
murmur at the apex radiating to the axilla
– S3 (CHF/LA overload)
– In chronic MR, the intensity of the murmur
does correlate with the severity.
• Exertion Dyspnea: ( exercise intolerance)
• Heart Failure: May coincide with increased
hemodynamic burden e.g., pregnancy,
infection or atrial fibrillation
The Natural History of MR
• Compensatory phase: 10-15 years
• Patients with asymptomatic severe MR have
a 5%/year mortality rate
• Once the patient’s EF becomes <60% and/or
becomes symptomatic, mortality rises sharply
• Mortality: From progressive dyspnea and
heart failure
Chronic Mitral Regurgitation
Diagnosis
• ECG: May show, LA enlargement, atrial fibrillation
and LV hypertrophy with severe MR
• CXR: LA enlargement, central pulmonary artery
enlargement.
• ECHO: Estimation of LA, LV size and function.
Valve structure assessment
– TEE if transthoracic echo is inconclusive
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Management of MR
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Medications
 Vasodilator such as hydralazine
 Rate control for atrial fibrillation with blockers, CCB, digoxin
 Anticoagulation in atrial fibrillation and
flutter
 Diuretics for fluid overload
Management of MR
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Serial Echocardiography:
– Mild: 2-3 years
– Moderate: 1-2 years
– Severe: 6-12 months
IE prophylaxis: Patients with prosthetic valves
or a Hx of IE for dental procedures.
Management Strategy for Patients With Chronic Severe
Mitral Regurgitation
Bonow, R. O. et al. J Am Coll Cardiol 2008;52:e1-e142
Mitral Valve Prolapse
Types
• Women 20 to 50 years
• Low BP, orthostatic hypotension, palpitations, chest pain
• Mid systolic click, maybe mid systolic murmur
• Echo:
- thickened, redundant leaflets
- leaflet excursion (prolapse) into LA in systole
- redundant chordae tendinae, trivial or mild MR
• Little progression of MR, Abx prophylaxis
Mitral Valve Prolapse
Types
• Men 40 to 70 years
• Myxomatous and thickened MV
• Significant leaflelt prolapse
• Significant MR, progressive MR
• Complications: Chordal rupture, Afib
• Endocarditis prophylaxis
• Surgery for MR often required
Classic or non-classic combined MVP equal in male and females. More
complications in MEN
Transthoracic echocardiographic image in parasternal long-axis view,
showing posterior mitral leaflet bowing backward and prolapsing into left
atrium during systole. LV=left ventricle. LA=left atrium. PML=posterior
mitral valve leaflet.
Aortic Regurgitation
Aortic Regurgitation Overview
• Definition: Leakage of blood into LV
during diastole due to ineffective
coaptation of the aortic cusps
Etiology of Acute AR
• Endocarditis
• Aortic Dissection
• Physical Findings:
– Wide pulse pressure
– Diastolic murmur
– Florid pulmonary edema
Treatment of Acute AR
• True Surgical Emergency
• Positive inotrope: (eg, dopamine,
dobutamine)
• Vasodilators: (eg, nitroprusside)
• Avoid beta-blockers
• Do not even consider a balloon pump
Etiology of Chronic AR
• Aortic leaflet disease
Bicuspid aortic valve
Rheumatic
Infective endocarditis
• Aortic root disease
Aortic aneurysm/dissection
Marfan’s syndrome
Connective tissue disorders
Syphilis
HTN
Annulo-aortic ectasia
Pathophysiology of AR
• Combined pressure AND volume overload
• Compensatory Mechanisms: LV dilation,
LVH. Progressive dilation leads to heart
failure
Pathophysiology of aortic regurgitation
Aortic regurgitation
LV volume
stroke volume
LV mass
systolic BP
LV dysfunction
diastolic BP
myocardial ischaemia
LV failure
Natural History of AR
• Asymptomatic until 4th or 5th decade
• Rate of Progression: 4-6% per year
• Progressive Symptoms include:
- Dyspnea: exertional, orthopnea, and
paroxsymal nocturnal dyspnea
- Nocturnal angina: due to slowing of heart rate
and reduction of diastolic blood pressure
- Palpitations: due to increased force of
contraction
Physical Exam findings of AR
• Wide pulse pressure: most sensitive
• Hyperdynamic and displaced apical impulse
• Auscultation– Diastolic blowing murmur at the left sternal border
– Austin flint murmur (apex): Regurgitant jet
impinges on anterior MVL causing it to vibrate
– Systolic ejection murmur: due to increased flow
across the aortic valve
水冲脉
Duroziez征
股动脉枪击音
毛细血管搏动
点头征
The Evaluation of AR
• CXR: enlarged cardiac silhouette and aortic root
enlargement
• ECHO: Evaluation of the AV and aortic root with
measurements of LV dimensions and function
(cornerstone for decision making and follow up
evaluation)
• Aortography: Used to confirm the severity of
disease
Example of a Jet of Aortic Regurgitation, as Shown by Color-Flow Imaging
Enriquez-Sarano, M. et al. N Engl J Med 2004;351:1539-1546
Management of AR
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General: IE prophylaxis in dental procedures
with a prosthetic AV or history of endocarditis.
Medical: Vasodilators (ACEI’s), dihydropyridine
calcium channel blocker improve stroke volume
and reduce regurgitation only if pt symptomatic
or HTN.
Serial Echocardiograms: to monitor progression.
Surgical Treatment: Definitive Tx
Percutaneous aortic valve implantation
Management Strategy for Patients With Chronic Severe
Aortic Regurgitation
Bonow, R. O. et al. J Am Coll Cardiol 2008;52:e1-e142
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