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1、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 伍伟锋 2013.7.27,一、瓣膜性心脏病治疗原则,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，而任何内科治疗或药物均不能使瓣膜病变消除或缓解治疗瓣膜性心脏病的关键就是修复或置换有病变的瓣膜 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（NYHA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膜 有充分的证据表明介入或手术治疗是有效和有益的，可提高长期存活率,二尖瓣狭窄治疗原则,内科药物治疗 心衰处理 房颤处理：心律转复、控制心率、抗血栓 介入或手术治疗,二、心衰内科
2、药物治疗,内科药物治疗在瓣膜病合并心衰是必要的和合理的 内科治疗主要包括 二尖瓣狭窄合并急性肺水肿的治疗 二尖瓣狭窄合并慢性心力衰竭的治疗,半卧位、吸氧、四肢交替结扎止血带 注射吗啡或哌替啶镇静 快速利尿 血管扩张剂 氨茶碱 去除诱因等,应避免使用以扩张小动脉为主减轻心脏后负荷的血管扩张药物 正性肌力药物对二尖瓣狭窄窦性心律时的肺水肿无益，仅在心房颤动伴快速心室率时可静脉注射西地兰以减慢心室率,与左室衰竭性肺水肿相同点,不同点与注意点,1、二尖瓣狭窄合并急性肺水肿的治疗,2、二尖瓣狭窄合并慢性心衰的内科治疗,纠正加重慢性心力衰竭的诱发因素 休息与限盐 利尿剂 正性肌力药物 （二狭合并房颤） 血
3、管扩张剂（禁用动脉血管扩张剂） 受体阻滞剂 （减慢心室率）,三、房颤处理,心律转复：电转、药物 控制心率：地高辛、受体阻滞剂 抗血栓：华法林,四、风湿热二级预防,五、心脏瓣膜病的介入治疗或外科手术,紧急PBMV,重症MS（MVA1.0cm2），处于应激状态容易发生急性肺水肿 适应证 MS肺水肿，内科治疗无效 合并休克，不能在内科治疗下缓解 心肺复苏后经内科积极治疗血流动力学仍难以稳定者,操作注意事项 操作敏捷，尽量减少不必要的程序 操作要准确，不可失误 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3例是在半卧位状态下，1位基础麻醉下完成操作,重症二尖瓣病变患者介入
4、新技术,1、二尖瓣经皮置换,Chinese 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),2
5、. Transcatheter mitral valve-in-valve implantation,36 patients (Since 2010) 4 case series of three or more patients have been reported with a total number of 23 patients. unpublished data of 13 additional patients Mean age was 78.45 9.2 years , All patients were in NYHA class III or IV,Cheung A, Al-
6、Lawati A. Transcatheter mitral valve-in-valve implantation: current experience and review of literature. Curr Opin Cardiol. 2013 Jan;28(2):181-6,Fluoroscopy sequence of transcatheter mitral valve-in-valve implantation in (A) a patient with prior aortic and mitral valve replacement. (B) The guidewire
7、 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.,(A) Two-dimensional echocardiography of the degenerated mitral valve bioprosthesis. The mechanism of failure was
8、 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.,median follow-up ranging from 70 to 357 days Thirty days mortality was 7.5% (n = 3) ,late mortality was 10% (n = 4) All patients had improvement in postoperative NYHA class to I/II The mitral regurgitation grade was reduced from 3+ or 4+ preoperatively to a grade of 0 or 1 postoperatively There was no structural valve deterioration reported in the follow-up period in any of the studies,谢谢！,
