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1 心脏瓣膜病的外科治疗 Surgical Treatment of Valvular Heart Disease 四川大学华西医院心脏外科侯江龙副教授

2 We can compare human s heart to a machine, which always works hard, from human s birth to death. It works day after day, year after year, has never taken a rest. So, what will happen if our machines become ill? Ok, now, let s together to study the valvular heart disease!

3 瓣膜疾病是临床常见但又比较复杂的问题不同部位的瓣膜病变所引起的病理病理生理血流动力学改变是不同的, 而同一部位瓣膜的不同病变所产生的病理病理生理血流动力学损害也是不同的尽管临床联合瓣膜损害多见, 但为便于了解, 下面从狭窄和返流 ( 关闭不全 ) 二个方面分别进行介绍

4 心脏瓣膜 (Normal)

5 二尖瓣狭窄 (Mitral Stenosis)

6 二尖瓣狭窄 (Mitral Stenosis) 病因 (Etiology ) Mitral stenosis (MS) is nearly always rheumatic in origin, it is rarely congenital. In patients with MS due to rheumatic fever, the pathological process causes leaflet thickening, calcification, commissural fusion, chordal fusion or a combination of these processes.

7 二尖瓣狭窄分级 The normal area of the mitral valve is 4 6 cm 2 Stenosis grading Orifice diameter (cm) Orifice area (cm 2 ) 轻度 (Mild) 中度 (moderate) 重度 (Severe) <0.8 < 1.0

8 病理生理 (Pathophysiology) The normal area of the mitral valve is 4 6 cm 2 <2.5cm 2 Mild/moderate stenosis Compensate left atrial dilatation <1cm 2 Severe stenosis Decompensate Left ventricular failure Elevated LA pressure Pulmonary 肺淤血, congestion 肺 and 动脉压升高 pulmonary hypertension Right ventricular failure Right ventricular hypertrophy and dilatation 8

9 左房压力增加左房长大 (>40mm) 和左房壁心肌纤维退行性改变最终出现心房纤颤 (Atrial Fibrilation,AF), 心脏瓣膜疾病患者中约 45%-60% 合并 AF AF 对机体的不利影响 :1 心排血量 30%, 心功能进一步降低 ;2 心腔进一步扩大, 心脏作功增加 ;3 病人出现心悸不适症状, 心率变化较大, 较难用洋地黄控制 ;4 体循环栓塞, 发生率约 40% AF 患者的病死率是无 AF 患者病死率的 2 倍 9

10 诊断 (Diagnosis ) Presentation : Dyspnea, exertional fatigue and orthopnea. Lifethreatening Pulmonary Edema occurs in advanced cases. P/E : pulse is irregular due to AF; loud 1st heart sound with an opening snap, followed by a low-pitched mid diastolic murmur. If RV failure is present : peripheral edema, elevated jugular venous pressure. Investigation : 2-D Echo is diagnostic; thickening and rigidity of the valve leaflets with dilation of the LA; TEE useful to see thrombus in the LA appendage; Doppler studies provides quanitative assessment of the pressure gradient across the mitral valve.

11 梨形心 (Pear-shaped heart) 二尖瓣面容 (Mitral facies)

12 超声心动图 (Echocardiography) 舒张期前叶呈圆拱状后叶活动度减少交界处粘连融合瓣叶增厚和瓣口面积缩小

13 二尖瓣狭窄 (Mitral Stenosis) Medical treatment Diurectics to control pulmonary and systemic congestion Digitalis to control the ventricular rate in AF Anticoagulation to protect against thromboembolism

14 二尖瓣狭窄 (Mitral Stenosis) 外科治疗策略 ( Strategy of surgical treatment) 瓣膜修复 (Valve repair) 闭式分离术或球囊扩张术 (Closed commissurotomy) 直视二尖瓣切开术 (Open mitral commissurotomy) 瓣膜替换 (Valve replacement)

15 闭式分离术或球囊扩张术手术指征 (Indication to Closed Commisurectomy) 单纯隔膜型二尖瓣狭窄, 瓣叶活动好, 无钙化窦性心律或房颤病史 <3 月无左房血栓心功能 II-III 级

16 二尖瓣闭式扩张术

17 二尖瓣球囊扩张术 Catheter Balloon valvotomy (Commissurotomy) For Non-calcified MS without MR ONLY 40% incidence of re-stenosis at 7 years Post-procedural develoment of MR

18 二尖瓣直视分离术适应症 (Indication to open mitral commissurotomy) 单纯二尖瓣狭窄瓣膜弹性好无钙化心功能 Ⅱ 级房颤 > 半年有栓塞史 / 左房血栓形成该手术方式在风湿性瓣膜疾病应用较少

19 二尖瓣直视分离术 ( 切开融合交界, 扩大瓣口, 切开分离粘连融合的腱索和乳头肌 )

20 二尖瓣置换术的适应症 (Indication to mitral valve replacement) 漏斗型二尖瓣狭窄有钙化再手术 ( 直视 / 闭式手术失败后 ) 合并感染性心内膜炎禁忌症 : 风湿活跃心脏恶病质不能耐受手术者

21 二尖瓣置换术

22 二尖瓣关闭不全 (Mitral Insufficiency)

23 二尖瓣关闭不全 (Mitral Insufficiency) 二尖瓣成形 (Mitrial valve repair) 利用病人自身组织和部分人工代用品修复二尖瓣装置, 包括瓣环的重建和缩小, 乳头肌和腱索的缩短或延长, 人工瓣环和人工腱索的植入, 瓣叶的修复等诸多成形技术二尖瓣关闭不全外科治疗的金标准 Golden Standard

24 二尖瓣成形术的优缺点 (Advantages/Disadvantages of mitral valve repair) 优点 : 保留了正常的瓣下装置, 有利于心功能维护无需终生抗凝缺点 : 个体化手术, 手术技术难度大有可能二次手术

25 二尖瓣关闭不全手术指征 (Indication for mitral insufficiency) 有临床症状的患者 Symptomatic 无临床症状但左心功能测值降低的患者, LV EF% 最新的观点中度及以上 MR 早期治疗

30 二尖瓣手术预后 (Prognosis ) 5 年生存率 80-90% ( 5 years Survival) 10 年生存率 70-80% (10 years Survival) 主要并发症 Major complication: 1. 出血及血栓栓塞 Thrombus/Embolism 2. 瓣膜功能异常 Valve dysfunction 3. 心衰 Heart Failure 4. 其他 Others

31 主动脉瓣狭窄 (Aortic Stenosis)

32 主动脉瓣狭窄分级 The normal area of the aortic valve is 3-4cm 2 Stenosis grading Mean transvalvular gradients(mmhg) Orifice area (cm 2 ) 轻度 (Mild) < 中度 (moderate) 重度 (Severe) >

33 主动脉瓣狭窄 (Aortic Stenosis) AS 是所有瓣膜病中预后最差的一种当患者出现症状后, 若未给予及时治疗, 情况往往急转直下有心衰的患者平均寿命约 1~2 年, 发生晕厥的患者平均寿命 2~3 年, 出现心绞痛的患者平均寿命约 4~5 年及时手术治疗

34 主动脉瓣狭窄手术适应症 (Indication to aortic stenosis) AVA < 0.75cm 2 或平均跨瓣压差 > 40mmHg, 峰值跨瓣压差 > 50mmHg, 无症状亦应手术出现症状即心绞痛晕厥或心衰等, 无论瓣膜狭窄的程度如何, 均应手术

35 主动脉瓣狭窄的外科治疗 (Surgical treatment of aortic stenosis) 主动脉瓣置换 (Aortic valve replacement) 常规胸骨正中切口 (Median sternotomy) 胸骨旁小切口或胸骨上段小切口 (Parasternal minimal incision or partial sternotomy) 经导管介入技术主动脉瓣置换 (Transcatheter Aortic Valve Implantation,TAVI)

37 Partial sternotomy Median sternotomy

40 主动脉瓣关闭不全 (Aortic insufficiency)

41 主动脉瓣关闭不全 (Aortic insufficiency) 主动脉瓣置换 (Aortic valve replacement) 是主要治疗方式. 临床上出现症状, 如心绞痛或左心衰竭等, 应尽早手术少数病人可以接受主动脉瓣成形术 (Aortic valve repair)

42 主动脉瓣关闭不全手术指征 (Indication for aortic insufficiency) 有症状的患者 Symptomatic patients Angina, heart failure, acute aortic regurgitation, endocarditis 无症状患者 Asymptomatic patients Progressive cardiac enlargement EF <45% or FS <25%, and EDD 70mm ESD 55mm

43 主动脉瓣膜置换术预后 (Prognosis)

44 临床上一个病人往往是联合瓣膜病变 ( 多个瓣膜病变, 狭窄合并关闭不全 ), 也可能合并其他心脏疾病 ( 如冠心病房颤胸主动脉瘤等等 ), 需要具体问题, 具体分析

45 人工心脏瓣膜 Prosthetic heart valve 机械瓣 (mechanical valve) 生物瓣 (Bioprosthesis )

46 人工瓣膜的比较机械瓣 (Mechanical valve) 血流动力学优良需要终生抗凝 Need for life-long anti-coagulation 抗凝相关并发症多经久耐用 Long life span 生物瓣 (Bioprosthesis) 血流动力学优良无需长期抗凝 No need for life-long anti-coagulation 避免抗凝相关并发症使用寿命短 (10-15 年 ) Relatively short life span Structural Failure requiring reoperation

47 机械瓣应用指征 (Indications for mechanical valve replacement) 年轻病人 (<65 岁 ) 合并房颤病人, 需要终生抗凝不接受二次手术的病人

50 生物瓣应用指征 (Indications for biological valve replacement) 老年病人, 窦性心律. 希望生育的年轻女性. 有抗凝禁忌的病人 ( 如有胃肠道出血病史或者从事高危职业的病人 ) 预期寿命 <10 年的病人 ( 如恶性肿瘤病人 )

52 微创心脏外科手术 Minimally Invasive Cardiac Surgery 腔镜下瓣膜置换 / 成形手术小切口主动脉瓣置换手术经心尖主动脉瓣置换手术

53 Thanks!

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untitled (Cardiac Insufficiency) (introduction) (Concept of heart failure) (Cardiac insufficiency & heart failure) (Concept of congestive heart failure) (Underlying and predisposing causes of heart failure) (Underlying