《二尖瓣狭窄病变治疗进展》由会员分享,可在线阅读,更多相关《二尖瓣狭窄病变治疗进展(23页珍藏版)》请在金锄头文库上搜索。
1、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一、瓣膜性心脏病治疗原那么一、瓣膜性心脏病治疗原那么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,而任何内科治疗或药物均不能使瓣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膜病变消除或缓解n治疗瓣膜性心脏病的关键就是修复或置换有病变的瓣膜治疗瓣膜性心脏病的关键就是修复或置换有病变的瓣膜n国际上较一致的意见是:所有有病症的瓣膜性心脏病心力国际上较一致的意见是:所有有病症的瓣膜性心脏病心
2、力衰竭衰竭NYHANYHA级及以上,以及重度主动脉瓣病变伴有晕级及以上,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厥、心绞痛者,均必须进行介入治疗或手术置换瓣膜n有充分的证据说明介入或手术治疗是有效和有益的,可提有充分的证据说明介入或手术治疗是有效和有益的,可提高长期存活率高长期存活率二尖瓣狭窄治疗原那么二尖瓣狭窄治疗原那么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
3、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 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应防止使用以扩张小动应防止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,仅在心房颤抖肿无益,仅在心房颤抖
4、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血管扩张剂禁用动脉血管扩张剂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三、房三、房颤处理理n心律心律转复:复
5、: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:华法林法林四、风湿热二级预防四、风湿热二级预防五、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紧急紧急PBMVPBMVn重症重症MSMSMVA1.0cm2MVA1.0cm2,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难心肺复苏后经内科积极治疗血流动力学仍难以稳定者以稳定者n操作本卷须知操作本卷须知n操作
6、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,扩张二尖瓣要足够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,阜外医院有大。术者必须是熟练者,阜外医院有3 3例是在半卧位例是在半卧位状态下,状态下,1 1位根底麻醉下完成操作位根底麻醉下完成操作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nChinese researchers first used a double-crowned fixation system on a Nitinol stent
7、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. Transcatheter mitral valve-in-valve implantationn36 patients (Since 2021)n4 case series of three
8、 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 litera
9、ture. Curr Opin Cardiol. 2021 Jan;28(2):181-6Fluoroscopy 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 delivere
10、d. 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 leaflet prolapse (*), (B) leading to severe regurgitation. After implantation of the SAPIEN valve, t
11、he prosthesis shows good anchorage with (C) full opening and (D) sufficient closure.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谢谢!谢谢!