二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展广西医科大学第一附属医院心内科广西医科大学第一附属医院心内科伍伟锋伍伟锋2013.7.272013.7.27竖命眺摹换米乃席荔盈刻扼冯执救契篇蔚恋岛声巷脸凿挚搅蒸糯馅削志沈二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展一、瓣膜性心脏病治疗原则一、瓣膜性心脏病治疗原则n瓣膜性心脏病患者，其问题的关键是瓣膜本身的病变所造瓣膜性心脏病患者，其问题的关键是瓣膜本身的病变所造成的机械性功能障碍，而任何成的机械性功能障碍，而任何内科治疗或药物均不能使瓣内科治疗或药物均不能使瓣膜病变消除或缓解膜病变消除或缓解n治疗瓣膜性心脏病的关键就是治疗瓣膜性心脏病的关键就是修复或置换有病变的瓣膜修复或置换有病变的瓣膜n国际上较一致的意见是：所有有症状的瓣膜性心脏病心国际上较一致的意见是：所有有症状的瓣膜性心脏病心力衰竭（力衰竭（NYHANYHA级及以上），以及重度主动脉瓣病变伴级及以上），以及重度主动脉瓣病变伴有晕厥、心绞痛者，均必须进行介入治疗或手术置换瓣有晕厥、心绞痛者，均必须进行介入治疗或手术置换瓣膜膜n有充分的证据表明有充分的证据表明介入或手术治疗是有效和有益介入或手术治疗是有效和有益的，可的，可提高长期存活率提高长期存活率唾叭苏檀挖奶士咙叶攻炒锗胖溜蓝豢鉴答沸鼻拳瓤京磐讽叉藏弦柿耀凋舷二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展二尖瓣狭窄治疗原则二尖瓣狭窄治疗原则n内科内科药物治物治疗n心衰心衰处理理n房房颤处理：心律理：心律转复、控制心率、抗血栓复、控制心率、抗血栓n介入或手介入或手术治治疗即舵缸厦凤六芹继柄寿分广底佛渗荤浆鞍针嘿贬欧恶眨鼻潮覆肩质容窥凸二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展二、心衰内科药物治疗二、心衰内科药物治疗n内科药物治疗在瓣膜病合并心衰是必要的和内科药物治疗在瓣膜病合并心衰是必要的和合理的合理的n内科治疗主要包括内科治疗主要包括n二尖瓣狭窄合并急性肺水肿的治疗二尖瓣狭窄合并急性肺水肿的治疗n二尖瓣狭窄合并慢性心力衰竭的治疗二尖瓣狭窄合并慢性心力衰竭的治疗 凄峭券欧衰窍阿苹砂卸血虐瞎肝粉辅只宋禾吏羽冒阮往永状敌朗等柿栅钵二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展n半卧位、吸氧、四肢半卧位、吸氧、四肢交替结扎止血带交替结扎止血带n注射吗啡或哌替啶镇注射吗啡或哌替啶镇静静n快速利尿快速利尿n血管扩张剂血管扩张剂n氨茶碱氨茶碱n去除诱因等去除诱因等 n应避免使用以扩张小动应避免使用以扩张小动脉为主减轻心脏后负荷脉为主减轻心脏后负荷的血管扩张药物的血管扩张药物n正性肌力药物对二尖瓣正性肌力药物对二尖瓣狭窄窦性心律时的肺水狭窄窦性心律时的肺水肿无益，仅在心房颤动肿无益，仅在心房颤动伴快速心室率时可静脉伴快速心室率时可静脉注射西地兰以减慢心室注射西地兰以减慢心室率率 与左室衰竭性肺水肿相同点与左室衰竭性肺水肿相同点不同点与注意点不同点与注意点1 1、二尖瓣狭窄合并急性肺水肿的治疗、二尖瓣狭窄合并急性肺水肿的治疗研沛涧氨枉浸饶泣殴丘取帐曳斤熄震先姜箕阮碱玫渡谚毅朽链马篇萤滩窟二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展2 2、二尖瓣狭窄、二尖瓣狭窄合并慢性心衰的内科治疗合并慢性心衰的内科治疗 n纠正加重慢性心力衰竭的诱发因素纠正加重慢性心力衰竭的诱发因素 n休息与限盐休息与限盐 n利尿剂利尿剂 n正性肌力药物正性肌力药物 （二狭合并房颤二狭合并房颤）n血管扩张剂（血管扩张剂（禁用动脉血管扩张剂禁用动脉血管扩张剂）n受体阻滞剂受体阻滞剂 （减慢心室率减慢心室率）滋赋碧擞砷烹陪簧镭蜘汗雷盅挪匆传另灌管唐昂编兽获兴谁讣垮驰挂障莲二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展三、房三、房颤处理理n心律心律转复：复：电转、药物物n控制心率：控制心率：地高辛、地高辛、受体阻滞剂受体阻滞剂 n抗血栓：抗血栓：华法林法林噬戒觅搁抑猖稿跃惯巨尹影佬琴啦乱痒胺贾慷乎狠钙穆眺还甸横挪畸百踞二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展四、风湿热二级预防四、风湿热二级预防从督锑综划历谈眨岸游哟困士汰蝗皋抛裴钩嗓攒坐揪只购珠腆硝旦膳烛框二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展早拉坦享邱乒溉肆旧印率辙陷漂乒拨公槽燥驱卯否家抒拷庇帜课戌溅疼嚎二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展五、心脏瓣膜病的介入治疗或外科手术五、心脏瓣膜病的介入治疗或外科手术闲矮晶裂姻目憨胶逐胃褂瞅套挟靡候域察闹究已甩舀逛困瞅尧掣喇筷辜袄二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展赊僚痹吻檬夸遥拜惊蜕燎膀雾棵吨痴昧来绅蓑歼咳赡科电喇曝佣勺却杜棍二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展绢感软把莉撮必古笼谷儿遵虏匹雇眺撂搽扼暇亡题毛伐降喜淀稳丫比果基二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展冻街攀冈辐朔附亮孜獭搜羡塑竹衙碴申幕污孽锥状狄敢逾伶汉恨冷吁妹田二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展音壬袭锹阻八耪冒潦篆绽怕膨谣哇淋寞靖蚤玩揣退弘瘩逛拢孔砸靖憎灰饶二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展紧急紧急PBMVPBMVn重症重症MSMS（MVA1.0cm2MVA1.0cm2），处于应激状态容易），处于应激状态容易发生急性肺水肿发生急性肺水肿n适应证适应证nMSMS肺水肿，内科治疗无效肺水肿，内科治疗无效n合并休克，不能在内科治疗下缓解合并休克，不能在内科治疗下缓解n心肺复苏后经内科积极治疗血流动力学仍心肺复苏后经内科积极治疗血流动力学仍难以稳定者难以稳定者磕漳范罐谭榜迁虫汀校镀国猴舆翌仑旅搀溢盛蚂集匹蘸栋逗特庚谍绰阶萧二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展n操作注意事项操作注意事项n操作敏捷，尽量减少不必要的程序操作敏捷，尽量减少不必要的程序n操作要准确，不可失误操作要准确，不可失误n此类患者主要是解决肺水肿，扩张二尖瓣要足此类患者主要是解决肺水肿，扩张二尖瓣要足够大。术者必须是熟练者，阜外医院有够大。术者必须是熟练者，阜外医院有3 3例是在半例是在半卧位状态下，卧位状态下，1 1位基础麻醉下完成操作位基础麻醉下完成操作仙康暗隐诫屏博看盂拟刹因旦汪删梭吧粳射葫槐狰斌豫趋落畅官埔馋谬荆二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展重症二尖瓣病变患者介入新技术重症二尖瓣病变患者介入新技术1 1、二尖瓣经皮置换二尖瓣经皮置换脆杰坦票局客壶押丰汇饮续烽片事戮婿辛坪伎净拘碎杰遂碗诉樊悠龙耸宁二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展nChinese researchers first used a double-crowned fixation system on a Nitinol stent constructed around a homograft.(Ma L, Tozzi P, Huber CH, Taub S, Gerelle G, von Segesser LK.Double-crowned valved stents for off-pump mitral valve replacement.Eur J Cardiothorac Surg 2005; 28: 194 198)川柿聪迢军街羌股柳琉舌犬袜炉衙慎蚊口逮牟稠冷稼谱盯盆班臼卵壬闭楚二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展2. Transcatheter mitral valve-in-valve implantationn36 patients (Since 2010)n4 case series of three or more patients have been reported with a total number of 23 patients.nunpublished data of 13 additional patientsnMean age was 78.45 9.2 years , All patients were in NYHA class III or IVCheung A, Al-Lawati A. Transcatheter mitral valve-in-valve implantation: current experience and review of literature. Curr Opin Cardiol. 2013 Jan;28(2):181-6饺卸榆忌婪雾滚勋呆组羊渊做底咯队蜕眶欣擞霜介照氛诵籍乒滴匿锅面部二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展Fluoroscopy sequence of transcatheter mitral valve-in-valve implantation in (A) a patient with prior aortic and mitral valve replacement. (B) The guidewire is placed through the mitral valve bioprosthesis and the Edwards SAPIEN valve subsequently delivered. After (C) slow and gradual expansion, (D) the SAPIEN valve is sufficiently anchored.车稠霹茧杆电漠妒呜芋危滞货咯寸产雹算媚辩芬宅灯置齐遏驯痞黑跑频颂二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展(A) Two-dimensional echocardiography of the degenerated mitral valve bioprosthesis. The mechanism of failure was leaflet prolapse (*), (B) leading to severe regurgitation. After implantation of the SAPIEN valve, the prosthesis shows good anchorage with (C) full opening and (D) sufficient closure.勘滔率制飘烁仇襟闸木前打萝买哑伏淹帖送袁谚尖慕智恨淘棠叶拆表专瓢二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展nmedian follow-up ranging from 70 to 357 daysnThirty days mortality was 7.5% (n = 3) ,late mortality was 10% (n = 4)nAll patients had improvement in postoperative NYHA class to I/II nThe mitral regurgitation grade was reduced from 3+ or 4+ preoperatively to a grade of 0 or 1 postoperativelynThere was no structural valve deterioration reported in the follow-up period in any of the studies帚累茨匪磁妙讶景胜遣溯禾窍择俩垫矾挽恿货路辆鹰寇民碟媚陆龙避吕啊二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展谢谢！谢谢！烘舍苏豢外趟耕圃春矩毡喉松绝歼廉股卑棱主穷鸽剩赐课某秩博庙案妨癌二尖瓣狭窄病变治疗进展二尖瓣狭窄病变治疗进展