Valvular Heart

Disease

Center of West China Medical SciencesSichuan University

【Pathology】

Single or multiple valves abnormalities caused by

inflamation、mucoid degeneration, retrogration,

congenital malformation, ischemic necrosis etc. , which

contribute to stenosis and regurgitation.

Rheumatic fever ------application of penecilin

Syphilis -----control of STD

Calcific aortic stenosis ----- population aging

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Valvular

Heart

Disease

MS MR AR AS

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Mitral Stenosis MS

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临床表现

症状

失代偿期

总论

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全面

检查

症状文字描述

X－ray

ECG

实验检查 体征 并发症

诊断

闭式分离

直视修补

人工瓣膜

球囊成形

理想适应

相对适应

禁忌

术前后对比

手术

疗 效

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MITRAL STENOSIS (VIEWED FROM BELOW

AND LEFT).

Funnel-shaped stenosis

Discrete membranous stenosis(not shown)

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◆Thicked stenotic

mitral

◆Enlargement of left

atrium

Mitral orifice

L. A.

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❑Normal mitral valve orifice area(MVOA): 4－6 cm2

❑Three stages:

MVOA ≤ 2 cm2 （mild stenosis）

MVOA ≤ 1.5 cm2 （moderate stenosis）

MVOA ≤ 1 cm2 （severe stenosis）

Compensated stage

Left atrium decompensated stage

Right ventricular decompensated stage

记忆法

2.0

1.51

【Pathophysiology】

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① Dyspnoea

❖Dyspnoea on exertion

❖Paroxysmal nocturnal dyspnea

（Vagus hypertonic）

❖Pulmonary oedema

1. Symptoms

【Clinical manifestations】

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❖② Palpitations or emboli from atrial

fibrillation

❖③ Haemoptysis (咯血)

❖④ Recurrent bronchitis and chogh

❖⑤ Crackdown symptom (压迫症状 )

【Clinical manifestations】1. Symptoms

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AORTA

L. PULMONARYARTERY

L. MAIN BRONCHUSL. UPPERPULMONARYVEIN

L. ATRIUM

The left bronchus cauda equina syndrome

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Compressionsymptoms

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【Signs】

Presystolic accentuation(收缩期前增强)

◆When left atrial contraction weakened the presystolic accentuation disappear;

◆The longer the murmur, the more severe the stenosis;

May combined with diastolic thrill .

① The characteristic diastolic low

frequency “rumble（隆隆样）” at

the apex

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②A loud S1 and the opening snap (OS)

(which indicates the valves are soft and

flexible).

The distance between S2 and the OA decreased as the LA pressure elevated

③ Pulmonary hypertension: P2 is loud and normally

split.

❖Systolic murmur

❖Relative pulmonary incompetence

❖Early-diastolic Graham – Steell murmur

【Signs】

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④中重度狭窄者呈二尖瓣面容Mitral face (malar flush)

二、体征 Signs (续 )

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右室肥厚时胸骨左缘及剑突下收缩期抬举式搏动示意图

如果自儿童期就有二尖瓣狭窄，因右室长大，

可见心前区隆起

【Examination】

❖LA enlargement

❖ Pear-shaped heart

❖ Mitral valve calcified

❖ Kerley B线(中重度肺郁血时，肺门阴影明显加深，肺下部血

管影减少而上部增多)

❖ Haemosiderosis (含铁血黄素沉积点状影 )

1. Chest X-ray

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Chest X-ray of rheumatic heart disease

The enlargement of the

right portion of the cardiac

silhouette.

The LA appendage is

dilated and forms a

localized bulge (arrow) on

the left cardiac border. 左房

正面观察

心影右缘扩大

左心耳扩大形成左心缘的局部膨隆

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❖ P mitrale(二尖瓣P波)

❖ Af (Atrial fibrillation)

❖ RV hypertrophy

2. E C G

【Examination】

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❖Ｍ型正常二尖瓣前叶活动曲线EF斜率正常 双峰存在前后瓣叶反向运动

【Examination】3. Echocardiogram

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❖Ｍ-Mode二尖瓣前叶活动曲线因EF 斜率减慢双峰消失呈城垛样

前后瓣叶同向运动

前叶增厚开放受限

左房增大

前叶

后叶

【Examination】3. Echocardiogram

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Echocardiogram of Normal MV

【Examination】

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2D long-axis (open)

Echocardiogram of MS

击此键心室舒张

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2D long-axis (close)

Echocardiogram of MS

击此键心室收缩

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2D short-axis (open)

Echocardiogram of MS

击此键心室收缩

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2D short-axis (close)

Echocardiogram of MS

击此键心室舒张

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Diagnosis &

Differential diagnosis

❖ Diastolic rumble in mitral area and LA enlargement;

❖UCG for further diagnosis

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❖ Austin-Flint murmur: caused by

severe aortic regurgitation.

❖Atrial myxoma (心房粘液瘤)

❖Mitral valve calcification

Differential diagnosis:

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Austin-Flint murmur

• Aortic

regurgitation;

• Blood flow

back and

impact against

the AMV;

• Causes

relatively

mitral stenosis.

击此键演动画

Austin-Flint murmur

• Aortic

regurgitation;

• Blood flow back

and impact

against the

AMV;

• Causes

relatively mitral

stenosis.

击此键演动画

❖ ATRIAL MYXOMA(心房粘液瘤)

较罕见，可出现MS的症状，体栓塞、全身不适及发热等，可类似 细菌性心内膜炎及SLE。肿瘤于舒张期进入二尖瓣口，收缩期进入心房，可出现特征性波状回波。如不手术切除，可导致死亡。

Differential diagnosis:

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Myxoma 心室收缩

ATRIAL

MYXOMA

带蒂的左房粘液瘤随心室的收缩和舒张上下活动

击此键心室舒张回总表

Myxoma 心室舒张ATRIAL

MYXOMA

带蒂的左房粘液瘤随心室的收缩和舒张上下活动

击此键心室收缩回总表

【Complication】

❖ Atrial fibrillation (more than 50%) : LV stroke

volume decrease by 20%, which induce or worsen the HF

❖ Systemic embolism (20%)

❖ Pulmonary infection

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complications

Acute pulmonary edema

Right heart failure

Endocarditis: rare

THROMBUS ATTACHED TO POSTERIOR WALL OF L. ATRIUM,

AND THROMBUS AT POSTEROMEDIAL COMMISSURE OF MITRAL VALVE

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【Treatment】

❖ A combination of surgery and medication;

❖ Prevention of complications;

Oral digoxin for chronic atrial fibrillation, and cardioversion if necessary.

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【Treatment for

decompensated stage】

❖Prevention of the streptococcus hemolyticus

infection;

❖Prophylaxis against the relapses of rheumatic

fever;

❖Prevention of infectious endocarditis:

preventive usage of medicine around the

surgery.

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【Treatment for

decompensated stage】

❖ Proper rest, limit the water intake, diuretics;

❖ Treatment for acute pulmonary edema;

❖ Management of massive hemoptysis ;

❖ Anticoagulation is necessary for Af patients;

❖ Artery embolectomy (动脉切开取栓术)

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❑ l. Ideal indications:

❖ ① Simple mitral stenosis(moderate-severe)，NYHA I-III,

and with apparent symptoms;

❖ ②Valves are elastic, without prominent calcification or

malformation; MVOA≤1.5cm2, without thrombus in LA

❖ ③ mean left atrial pressure ＞1.46 kPa (11 mmHg)，

pressure difference across the mitral valve in diastole ＞

1.06 kPa （3 mmHg）。

(经皮球囊扩张瓣膜成形术 )

【Percutaneous Mitral Balloon Valvulopastay】

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❑ 2，Relative indications:

❖ Restenosis

❖ Atrial fibrillation

❖ Mitral valve calcification

❖ Combined with mitral or aortic regurgitation

❖ Pulmonary hypertension

❖ Heart failure

❖ Patients who can not afford anticoagulation treatment

【Percutaneous Mitral Balloon Valvulopastay】(经皮球囊扩张瓣膜成形术 )

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❑ 3. Abstinence❖ Active rheumatism, severe arrhythmia, severe heart

dysfunction, thrombosis history；

❖ Severe MV calcification or malformation, combinedwith severe mitral or aortic regurgitation;

❖ Left atrial mural thrombus;

❖ Patients who are with contraindication for Ventricular septal puncture

【Percutaneous Mitral Balloon Valvulopastay】

(经皮球囊扩张瓣膜成形术 )

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【球囊扩张术的疗效】

平均瓣口面积可增加 1Cm2。术后 93 ~ 100 %

患者的症状和 心功能可改善。

优点：创伤小、痛苦少，相对安全且康复快

并发症：体循环栓塞、左心室穿孔、心包

填塞、房缺、二尖瓣回流、室性心动过速和

房性心律失常、房室传导阻滞、穿剌部位 血

管损伤、出血、低血压和球囊破裂等。

术后1年有 8% 再狭窄。

Effect of PMBV

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动画

二尖瓣球囊成形术示意图

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二尖瓣球囊成形术

球囊到位充盈时球囊中部被狭窄的

二尖瓣压迫成“腰征”

球囊完全膨胀“腰征”消失

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Chest X-ray of PMBV patient

术 前 术后九个月回总表

【Surgical treatment】

❖ Indication：

➢ Same as PMBV

Closed mitral commissurotomy(闭式分离术)

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闭式分离术（3／3）

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❖ 对合并存在的关闭不全可

作适当缝补或进行瓣环成

形术。

【Surgical treatment】直视下修补术

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❖指征 : 心功能在 3～4 级且合并有明显

主动脉瓣 疾病或／及主动脉瓣回流导致

左室明显增大，或瓣膜广泛重度 钙化以

致不能分离修补者以及钙化粥样瘤引起

狭窄者 均适用 瓣膜替 换术。

【Surgical treatment】人工瓣膜替换术

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❖机械瓣优点：耐用，不排异，不钙化

❑缺点

❑：终生抗凝，伴有溃疡病或出血性疾病

者忌用，以后难再接受其他手术。

【Surgical treatment】

机械瓣替换术

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❖ 生物瓣

优点：术后不需长期抗凝，极少排异；

缺点：可因感染性心内膜炎或在若干年

后因钙化或/及机械性损伤而失效。

【Surgical treatment】生物瓣替换术

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West China Medical Center of sichuan University

Mitral Regurgitation

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【Etiology】

Rheumatic heart disease

Mitral prolapse

Ischaemic papillary muscle dysfunction

Cardiomyopathy

Marfan’s syndrome

Infectious endocarditis and chordae tendinca rupture(腱索断裂)

症状总结表

早期无明显症状，可保持较长时间，甚至超过20年.一旦出现明显症状，多已有不可逆心功损害。心悸 咳嗽 劳力性呼吸困难 乏力，但急性肺水肿、咯血及栓塞少

【Clinical manifestation】

Signs：

murmur：

❖ systolic murmur

❖ diastolic murmur( when MR is severe)

❖ heart failure (caused by relative mitral stenosis may) happened, murmur intensity decreased.

2. Signs ② left ventricle enlargement in the late

stage

Left ventricular enlargement

心尖搏动

【Examination】

❖Ｘ-ray: left atrium and ventricle

enlargement in late stage

❖ECG: left ventricular enlargement and

hypertrophy

❖UCG: helpful in differentiating etiology

and evaluating LV function.

X-Ray chestL. and R.

Ventricular

Enlargement

ECG

Electrocardiographic Evidence of L. Ventricular

Hypertrophy (Large S in V1, Large R in V4) and

Minor Atrial Abnormality (Broad P)

【Diagnosis and differential diagnosis】

Typical systolic murmur at the apex;

LV enlargement in the middle-late

stage;

Distinguish from other murmurs:

1. physiologic murmur

2. mitral valve prolapse(二尖瓣脱垂)

【Diagnosis and differential diagnosis】

UCG image of mitral valve prolapse

二尖瓣脱垂的超声心动图表现 二尖瓣前叶

二尖瓣脱垂 呈吊床样改变

二尖瓣后叶

Mitral Valve prolapse（二尖瓣脱垂）

late systolic clicks

Can be found in two conditions:

Valve worn out(middle aged and elderly),

chordae tendineae and papillary muscles abnormal

after infarction

Valves are soft in youth especially thin women

May combined with arrhythmia, syncope,untypical

chest pain, transient myocardial ischemia and

infectious myocarditis.

【Complication】

Similar to mitral valve

stenosis(relatively late stage);

Infectious myocarditis（more common

than in MS)

Thrombosis is rare to see

【 Treatment 】

Medical therapy

Similar to mitral stenosis

第一节

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【 Treatment 】

Surgical therapy

Valve replacement：early surgery

第二节

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Aortic valvular disease

Aortic Stenosis(AS）

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AORTIC VALVE: FUSION OF RIGHT CUSP AND POSTERIOR CUSP, RESULTING IN A BICUSPID VALVE WHICH IS STILL COMPETENT

病解：

主动脉瓣狭窄：

右瓣与后瓣粘连

形成二叶式主动

脉瓣

【Etiology】

❖ <60y Rheumatic or congenital;

❖ 60～75y Calcified congenital bicuspid

valve (more common in man)

❖ >75y Degenerative calcification(more

common in woman)

【Clinical manifestation】

dyspnea

Angina (about 50% patients suffered)

2/3 were combined with coronary artery disease

Syncope labor induced, may be the first sign

Sudden cardiac death

Mechanism of angina

正常

异常

【Clinical manifestation】

Left ventricular enlargement

(Sustained and heaving apex beat)

Systolic ejection murmur at aortic area and systolic

thrill

The murmur is louder if combined with AR

The murmur is weaker if combined with HF or MR。

The murmur intensity doesn’t match the severity of

stenosis，but depends on stroke volume

S 1 is commonly normal, when combined

with ejection sound indicates a mild

calcification and elastic valves.

A 2 weakens(valve movement is limited)

S 2 paradoxical splitting (delayed LV

emptying)

Auscultation:

【Diagnosis and differential diagnosis】

Systolic ejection murmur at

aortic area and systolic thrill

UCG may help to distinguish

the etiology

Differentiate from

hypertrophic obstructive

cardiomyopathy

【Treatment】

经皮球囊扩张瓣膜成形术有良好效果

风湿性者不仅常伴主动脉瓣关闭不全

而且常伴二尖瓣病变，应全面考虑。

对暂无手术适应证的无症状病人

应根据狭窄程度适当限制体力活动。

每半年或一年复查，以便及时手术治疗。

特别注意预防感染性心内膜炎。

❑慎用利尿剂和作用于小动脉的血管扩张剂

Medical treatment

AS balloon angioplasty （1）

球囊瓣膜成形导管

狭窄主动脉瓣

导引钢丝

AS balloon angioplasty （2）

❖ 瓣膜狭窄程度重，变形显著，钙化重而广

❖ 估计难以分离或合并显著关闭不全时

❖ 均应作瓣膜替换术

❖ 术前均应作心导管术及心血管造影术

❖ 对老年人及有心绞痛史者应加作冠状动脉造影

❖ 以全面了解心脏冠脉结构及血流动力学状况

❖ 风湿性者常合并二尖瓣病变，处理原则与无症状者同

❖ 其症状究系由二尖瓣病变抑或AS引起，应全面分析考虑

【Treatment】Surgical

treatment

Aortic Valvular

Incompetence

Aortic Regurgitation(AR)

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病解 AORTIC INSUFFICIENCY: VALVE VIEWED FROM ABOVE, THICKENED, SHORT CUSPS WITH TRIANGULR DEFICIENCY

【Clinical manifestation】

Chest Pain

Palpitation

Other symptoms

Strong artery throbbing sensation

symptoms of cerebral ischemia

Mechanism of angina

正常

异常

Early diastolic blowing murmur at aortic area;

Austin Flint murmur at apex

Other signs:

A 2 weakens or disappears indicates valve is

inflexible;

Systolic murmur at aortic area：ascending aortic

root dilated , relative aortic stenosis;

Heaving apex impulse when LV dilated

Boot-shaped heart

【Sign】

❖ Carotid pulsation marked(颈动脉搏动增强 )

❖ Water-hammer(水冲脉 ) Collapsing(塌陷脉）

❖ Pistol shot sounds（枪击声）

❖ Capillary pulsations（毛细血管搏动）

❖ Duroziez sign（杜柔双重音）

❖ De-Musset sign：头部随心搏频率作上下摆动

❖ Hill’s sign:下肢动脉收缩压较肱动脉高出

5.3KPa(40mmHg)以上,而正常人只高出1.3 - 2.7KPa

【Peripheral vascular sign】

【Diagnosis and differential diagnosis】

Typical early diastolic murmur at 3rd intercostal space left to sternum;2D and Doppler echocardiography may help to testify. Occasionally Doppler is the only evidence;Distinguish from Graham-Steell murmur;Rheumatic chronic aortic regurgitation:因病情发

展缓慢，由相当长的无症状期（无心衰）到心肌衰竭期（EF下降）最后发展到充血性心力衰竭期。

【Treatment】❖对无症状病人应定期复查，如心脏增大，左室肥厚伴劳损 心电图或左室腔内径增大有发展，应采用放射性核素心血管造影术，心阻抗图，超声心动图等测定左室功能。

❖如下降，表明有心肌衰竭，应及早换瓣。❖如到已有充血性心衰时方换瓣则死亡率高手术效果不理想。

❖在无症状期，还应适当限制体力活动❖控制可治疗的伴发症如高血压、冠心病❖预防感染性心内膜炎及一切可诱发心衰的致病因素。

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