3.acquired valvular heart disease

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CHAÅN ÑOAÙN HÌNH AÛNH BEÄNH VAN TIM MAÉC PHAÛI

BS.NGUYEÃN QUYÙ KHOAÙNG

BS.NGUYEÃN QUANG TROÏNG

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DAØN BAØI

� Heïp van 2 laù.� Ñaïi cöông.� X quang Heïp van 2 laù nheï.� X quang Heïp van 2 laù trung bình-naëng.

�Thay ñoåi veà tim.�Thay ñoåi veà maïch maùu.�Thay ñoåi veà chuû moâ phoåi.

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DAØN BAØI

� Hôû van 2 laù.� Ñaïi cöông.� X quang Hôû van 2 laù nheï.� X quang Hôû van 2 laù trung bình.� X quang Heïp van 2 laù naëng.� Caùc theå keát hôïp.

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DAØN BAØI

� Heïp van Ñoäng maïch chuû.� Ñaïi cöông.� X quang.� Coäng höôûng töø.

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DAØN BAØI

� Hôû van Ñoäng maïch chuû.� Ñaïi cöông.� X quang.� Chuïp coù caûn quang.� Coäng höôûng töø.

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DAØN BAØI

� Beänh lyù van Ñoäng maïch phoåi.� Beänh lyù van 3 laù.

ÖÙng duïng laâm saøng.� Keát luaän.

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ÑAÏI CÖÔNGHEÏP VAN HAI LAÙ

(MITRAL STENOSIS)

� Beänh thöôøng gaëp ôû Vieät Nam.� 50% laø do Thaáp tim (RAA).Nöõ/Nam=8/1.� Caùc nguyeân nhaân khaùc:

� Vieâm noäi taâm maïc nhieãm truøng (Bacterial endocarditis).

� U nhaày nhó (T)(LA myxoma).

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ÑAÏI CÖÔNGHEÏP VAN HAI LAÙ

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X QUANGHEÏP VAN HAI LAÙ NHEÏ

� Bình thöôøng S loã van=4-6cm2.� Heïp nheï khi 2cm2 ≤ S < 4cm2.

� AÙp löïc mao maïch phoåi =10-12mmHg. � Laâm saøng: Rung taâm tröông (+).

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NORMAL MITRAL VALVE MITRAL STENOSIS

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� X quang: � Boùng tim chöa thaáy thay ñoåi gì.� Phaân boá maïch maùu phoåi cuõng chöa

thaáy thay ñoåi.� Do vaäy,X quang tim-phoåi bình thöôøng

khoâng loaïi tröø ñöôïc Heïp van hai laù.

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X QUANGHEÏP VAN HAI LAÙ TRUNG BÌNH-NAËNG

� Heïp trung bình khi 1cm2 ≤ S < 2cm2.� AÙp löïc mao maïch phoåi =10-17mmHg.

� Heïp naëng khi S loã van < 1cm2.� AÙp löïc mao maïch phoåi ≥18mmHg.

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� Sinh lyù beänh:� Taéc ngheõn doøng chaûy töø Nhó (T)

xuoáng Thaát (T)�Taêng aùp löïc Nhó (T) �Daõn buoàng Nhó (T)�Taêng aùp löïc TM phoåi�Taêng aùp löïc ÑM phoåi�Taêng aùp löïc Thaát (P)�Giaõn buoàng Thaát (P).

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THAY ÑOÅI VEÀ TIM

� Daõn buoàng Nhó (T) khi ñöôøng kính Nhó (T)>7cm (ño töø bôø döôùi PQ goác (T) ñeán bôø phaûi Nhó (T)).

� Pheá quaûn goác (T) bò ñaåy leân cao.� Coù hình aûnh bôø ñoâi ôû bôø (P) cuûa tim.

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� ÑgMC xuoáng bò ñaåy qua (T).� Phim thaúng coù uoáng Baryte:Thöïc quaûn

coù theå bò ñaåy leäch,thöôøng laø qua (P),ñoâi khi bò ñaåy leäch qua (T).

� Phim cheách tröôùc (P)(RAO) coù uoáng Baryte:Thöïc quaûn bò ñaåy ra sau roõ nhaát.

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THAY ÑOÅI VEÀ TIMLEFT ATRIAL ENLARGEMENT is best confirmed by measuring the distance from the midinferior border of the left main bronchus to the right lateral border of the left atrial density.

-This distance is less than 7cm in 90% of normal patients and is greater than 7cm in 90% of left atrial enlargement patients,as proven by echocardiography.

-This measurement can be approximated by placing one’s right fifth finger under the left bronchus,and while keeping the fingers closed,if the left atrium is seen beyond one’s four fingertips,the left atrium is enlarged.

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PULMONARY EDEMA / MITRAL STENOSIS

AFTER TREATMENT

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MITRAL STENOSIS

Enlarged LAA

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Enlargement of the left atrial appendage.

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-Elevation of left main bronchus.

-Double shadow of the large left atrium (arrow).

-Right atrial border is limited below by the entry of the inferior vena cava.

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-Elevation of left main bronchus.

-Splaying of the carina.

-Descending aorta (arrow) has been displaced to the left by the large left atrium.

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RAO-MITRAL STENOSIS

Enlarged LA

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� Caøng ngaøy Nhó (T) caøng to ra,nhaát laø khi coù Rung nhó.Nhó (T)coù theå vöôït ra ngoaøi bôø Nhó (P).

� Cung ÑMP cuõng to ra do taêng aùp trong buoàng Thaát (P).

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� Tieåu nhó (T) daõn lôùn bieåu hieän baèng cung thöù 4 beân (T),ngay döôùi cung ÑM phoåi.Ñaây laø daáu hieäu coù sôùm nhaát cuûa Heïp van 2 laù.

� Bôø (T) tim cuõng coù theå bieåu hieän laø moät ñöôøng thaúng hoaëc loài ra (Mitralisation du bord gauche du coeur).

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� Hieän töôïng Mitralisation roõ laø nhôø Quai ÑMC nhoû do giaûm cung löôïng tim (löôïng maùu veà Thaát (T) ít).

� Neáu Quai ÑMC to,caàn phaûi chuù yù xem coù keát hôïp theâm beänh khaùc nhö Heïp van ÑMC,Hôû van ÑMC.

� Quai TM Azygos daõn (>7mm).

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� Thaát (T) coù kích thöôùc bình thöôøng,chæ soá T/N ≤ 0,5.

� Veà sau Thaát (P) daõn� Chæ soá T/N taêng. (Khoù chaån ñoaùn phaân bieät vôùi Daøy thaát (T) treân hình thaúng,caàn hình nghieâng (T)-Thaát (P) che laáp khoaûng saùng sau öùc).

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� Hình aûnh ít gaëp laø voâi hoùa van hai laù(40%), voøng van 2 laù(10%) vaø ôû thaønh Nhó (T).

� Phim nghieâng (T):Nhó (T) to ñaåy PQ goác (T) ra sau (Walking man sign).

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MITRAL STENOSIS

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THAY ÑOÅI VEÀ TIM-Enlarged veins.

-Bulging of the pulmonary artery.

-Double density due to enlarged left atrium.

-Right lateral displacement of esophagus.

SEVERE MITRAL STENOSIS

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X QUANGCHAÅN ÑOAÙN PHAÂN BIEÄT

Pectus excavatum-Cardiac silhouette is rotated and displaced to the patient’s left,and the left cardiac border is straight simulating mitral valve disease.

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10-year-old asymptomatic boy with an unusual contour of the left upper heart border on a chest X-ray.

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Coronal T1-weighted:Bulging of the left atrial appendage related to partial absence of the pericardium.

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PARTIAL ABSENCE OF THE PERICARDIUM

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WALKING MAN SIGN

-The right main bronchus is outlined.

-The lower lobe bronchus is displaced posteriorly (large arrowheads).

-Calcification of the wall of the left atrium (small arrowheads).

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-RAO:enlargement of the left atrium(large black arrow).

-The mitral valve is calcified(small black arrow).

-The pulmonary outflow tract is enlarged(white arrow).

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C-shaped calcification in the mitral valve ring-Lateral view.

Calcification in the wall of the left atrium.

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Calcification within the left atrium.

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Left atrial calcification

(Lateral view).

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-Left atrial calcification (white arrows).

-Calcified mitral valve (black arrow).

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-Calcified mitral valve.

-Esophagus is pushed posteriorly by the enlarged left atrium.

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X QUANGTHAY ÑOÅI VEÀ TIM

Mitral annular calcification in asymptomatic patients.

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THAY ÑOÅI VEÀ TUAÀN HOAØN PHOÅI

� Taêng tuaàn hoaøn phoåi thuï ñoäng (Taêng tuaàn hoaøn phoåi sau mao maïch):� Taùi phaân phoái maïch maùu phoåi xuaát

hieän sôùm khi ALTT>12mmHg.� Xuaát hieän caùc ñöôøng Kerley A,B,C,D

khi ALTT>18mmHg.Thöôøng thaáy nhaát laø Kerley B.

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� ÑMP to daàn�Khoù chaån ñoaùn phaân bieät giöõa CIA vôùi RM+HVD.� CIA:Nhó (T) khoâng to,khoâng coù taùi

phaân phoái.� Veà sau,ÑMP to ôû trung taâm,nhoû ôû ngoaïi

vi (Tình traïng taêng aùp ÑMP laâu ngaøy�Thaønh tieåu ñoäng maïch daøy leân).

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Tuần hoàn phổi bình thường Tái phân phối mạch máu phổi

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Dày vách liên tiểu thùy

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CARDIAC FAILURE

-Enlarged heart size.

-No clear heart border (interstitiel edema), Kerley’s line, pleural effusion.

-Redistribution.

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-Left ventricle has normal size.

-Dilated upper lobe vessels.

-Bulging of the left atrial appendage.

-Elevation of the left main bronchus.

-Double contour of the right heart border.

MITRAL STENOSIS

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THAY ÑOÅI VEÀ TUAÀN HOAØN PHOÅI-Small aortic knob.

-Bulging of the main pulmonary artery.

-Bulging of the left atrial appendage(large white arrow).

-Elevation of the left main bronchus(black arrowheads).

-Double density through the heart shadow(black arrows).

-Redistribution(small white arrows).

-The hilar vasculature is prominent(white arrowhead).

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-Dilated upper lobe vessels.



-Double contour of the right heart border.

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-Left main bronchus is displaced posteriorly by the large left atrium.

-Large right ventricle touches the sternum.

MITRAL STENOSIS

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PULMONARY ARTERIAL ANEURYSM / SEVERE MITRAL STENOSIS

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THAY ÑOÅI VEÀ CHUÛ MOÂ PHOÅI-CAÁP TÍNH

� Phuø phoåi moâ keõ.� Phuø phoåi pheá nang.

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PULMONARY INTERSTITIAL EDEMA

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PULMONARY EDEMA

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THAY ÑOÅI VEÀ CHUÛ MOÂ PHOÅI-MAÏN TÍNH

� ÔÛ ngöôøi Heïp van 2 laù laâu naêm, 1/3 giöõa vaø 1/3 döôùi coù nhöõng ñoám Hemosiderine do Hb thoaùt ra ngoaøi Hoàng caàu (1/3 döôùi nhieàu hôn 1/3 giöõa).

� Hemosiderine bò aên bôûi Ñaïi thöïc baøo�Hemosiderose.

� Phaân bieät vôùiLao phoåi keâ:Noát keâ raûi khaép phoåi (caû 3 phaàn treân,giöõa vaø döôùi phoåi).

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� Xô phoåi:nhöõng daûi môø saéc neùt.� Daøy dính maøng phoåi:do thoaùt

dòch�Daøy dính.� Nhöõng vuøng môø cuûa nhoài maùu phoåi

cuõ.

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� Nhoài maùu phoåi (Pulmonary infarction) laø moät bieán chöùng thöôøng gaëp cuûa beänh van 2 laù vì thuyeân taéc coù nguoàn goác töø:� Hoaëc do nhöõng cuïc maùu ñoâng ôû ngoaïi

vi vì cung löôïng tim thaáp.� Hoaëc do cuïc maùu ñoâng töø Nhó (P) xuaát

hieän sau Rung nhó.

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-The cardiac silhouette is typical of mitral stenosis.

-Consolidation and pleural reaction at the left base�pulmonary infarction.

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HEMOSIDEROSIS IN MITRAL STENOSIS

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KERLEY’S B LINES & HEMOSIDEROSIS IN MITRAL STENOSIS

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ÑAÏI CÖÔNGHÔÛ VAN HAI LAÙ

(MITRAL REGURGITATION)

� Hôû van 2 laù coù theå caáp tính:Ñöùt daây chaèng-coät cô (sau Nhoài maùu cô tim,Vieâm noäi taâm maïc nhieãm truøng)�Hôû 2 laù nhöng Thaát (T) chöa kòp giaõn roäng.

� Hôû van 2 laù coù theå maïn tính:Sau RAA, hoaëc do loã van giaõn roäng (Hoäi chöùng Marfan, Beänh cô tim)…

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X QUANGHÔÛ VAN HAI LAÙ NHEÏ

� Thaát (T) vaø Nhó (T) giaõn lôùn do “overload”.� Nhó (T) coøn buø � X quang tim-phoåi bình

thöôøng duø treân Laâm saøng nghe ATTT.� Do vaäy,cuõng nhö Heïp van 2 laù,X quang

tim-phoåi bình thöôøng khoâng loaïi tröø ñöôïc Hôû van 2 laù.

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X QUANGHÔÛ VAN HAI LAÙ TRUNG BÌNH

� Nhó (T) coøn buø.� Nhó (T) to ra,nhöng aùp suaát chöa taêng

nhieàu.� Thaát (T) cuõng giaõn to vöøa phaûi.� Quai ÑMC nhoû do cung löôïng tim giaûm.

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X QUANGHÔÛ VAN HAI LAÙ NAËNG

� Nhó (T) maát buø.� Nhó (T) to ra,aùp suaát taêng cao.Neáu so

saùnh vôùi Heïp 2 laù ,thì Nhó (T) to hôn nhieàu,coù khi vöôït ra ngoaøi bôø cuûa Nhó (P).

� Thaát (T) to ra,taïo neân hình aûnh “big heart disease”.

� Treân hình nghieâng hoaëc LAO: Thaát (T) to che laáp khoaûng saùng sau tim.

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� Quai ÑMC nhoû do cung löôïng tim giaûm.� Phình cung ÑMP�”Mitralisation du bord

gauche du coeur”.� Taùi phaân phoái tuaàn hoaøn phoåi.� Caùc ñöôøng Kerley ít gaëp hôn vaø khoâng

roõ so vôùi Heïp van 2 laù.

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MITRAL REGURGITATION

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-Small aortic knob.

-Peribronchial cuffing due to edema.


-Left ventricular enlargement.

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-Straightening of the left heart border.

-Small aortic knob.



-Huge left atrium.

-Enlargement of the cardiac silhouette.

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Enlarged left atrium.


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LATERAL VIEW:RETROGRADE BRACHIAL ARTERY CATHETERIZATION.

-Left ventricle (small arrows).

-Contrast through the incompetent mitral valve into the large left atrium (arrowheads).

-Filling of the pulmonary veins (large arrows).


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-Small aortic knob.


-Enlargement of the left ventricle and left atrium.

-The left atrium is calcified (arrowheads).

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Calcification of the left atrial wall


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-Small aortic knob.

-Bulging of the main pulmonary artery.


-Extreme enlargement of the left atrium.


-Small right pleural effusion.

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Calcification of the posterior wall of the huge left atrium.


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-Small aortic knob.


-Extreme enlargement of the left atrium (arrows).


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SIEÂU AÂMHÔÛ VAN HAI LAÙ

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PA view:Dilated left atrial appendage (arrows).

Displacement of the left ventricular contour toward the left chest wall.

LAT view:Dilated left atrium and ventricle.


RETROGRADE LEFT VENTRICULOGRAM: Dilated left atrium and left atrial appendage (arrows).

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X QUANGCAÙC THEÅ KEÁT HÔÏP

� Heïp+Hôû van 2 laù:Nhó (T) raát lôùn,coù ñoùng voâi ôû van 2 laù vaø thaønh Nhó (T),tim to toaøn boä.

� Hôû van 2 laù+Beänh van ÑMC(Heïp,hôû).� Hôû van 2 laù+Hôû van 3 laù.� Hôû van 2 laù+Hôû van 3 laù+Beänh van

ÑMC.

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Mitral valve stenosis and regurgitation-

prosthetic mitral valve

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MITRAL STENOSIS AND MITRAL REGURGITATION

-Small aortic knob.

-Enlarged pulmonary artery(2).

-Enlarged left atrial appendage(3).

-Enlarged left ventricle(4).

-Double atrial contour(1).

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-Typical cardiac configuration of mitral valvular disease.

-Calcification of the mitral valve (black arrows).

-Calcific density in the left ventricle (white arrows).

(Thrombus arose in the left atrium �Prolapsed into the left ventricle �Calcified thrombus).

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RAO-Calcification of the mitral valve (black arrows).-Calcific density in the left ventricle (white arrows).


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-Small aortic knob.

-Bulging of the main pulmonary artery (white arrow).

-Enlargement of the left ventricle (large arrowheads).

-Enlargement of the left atrium.

-Prominent of the superior pulmonary veins (small arrowhead).

-Kerley’s B lines.


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-Elevation of the left main bronchus (black arrow).

-Enlargement of the left ventricle (arrowhead).


The aortic valvular lesions was not suspected.It is often impossible to diagnose the combined lesion on plain films.


AND AORTIC REGURGITATION

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SEVERE MITRAL VALVE DISEASE

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ÑAÏI CÖÔNGHEÏP VAN ÑOÄNG MAÏCH CHUÛ

(AORTIC STENOSIS)

� Bình thöôøng SAO=2,5-3,5 cm2.� Khi SAO < 0,7cm2�Coù trieäu chöùng laâm

saøng.� Sinh lyù beänh:Heïp van ÑMC�Taêng gaùnh

Thaát (T)�Daøy ñoàng taâm Thaát (T). � Giaõn sau heïp ôû ÑMC leân,thaáy roõ treân

phim LAO.

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X QUANGHEÏP VAN ÑOÄNG MAÏCH CHUÛ

� Bôø tim beân (T) baàu do daøy ñoàng taâm Thaát (T),chæ soá T/N # 0,55.

� ÑMC leân cong qua (P).� Quai ÑMC khoâng to vì löu löôïng ÑMC

giaûm.� Veà sau:

� Moûm tim chuùc xuoáng do giaõn thaát (T).� Ñoùng voâi ôû van ÑMC (85%-sau RAA).

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� Phoái hôïp:Heïp van ÑMC+Heïp van 2 laù.� ÔÛ ngöôøi treû,Heïp van ÑMC baåm sinh=

Van 2 maûnh (Bicuspid valve).� Chaån ñoaùn phaân bieät:

� Cao huyeát aùp.� Xô vöõa ÑMC.

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AORTIC STENOSIS

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AORTIC STENOSIS

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Calcifications in the heart lie on a line drawn between the sterno-diaphragmatic angle

and the carina.

CALCIFIED AORTIC VALVE

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Ascending aorta shows slight post-stenotic

dilatation.

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-Aortic valve calcification (arrow).

-Posterior displacement of the left ventricle behind the line of the inferior vena cava.

AORTIC STENOSIS

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-Normal heart size.

-Dilated ascending aorta.

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Calcified aortic valve.

AORTIC STENOSIS

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-Rounded left heart border (arrowheads).

-Dilated ascending aorta (small arrows).

-The aortic knob is not enlarged.

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LAO

-Bulging of the ascending aorta because of post-stenotic dilatation (arrowheads).

-Calcified aortic valve (black arrow).

AORTIC STENOSIS

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AORTIC AND MITRAL STENOSIS

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COÄNG HÖÔÛNG TÖØHEÏP VAN ÑOÄNG MAÏCH CHUÛ

GRADIENT-ECHO MR

-Aortic valve (arrow).

-The signal void in the entire ascending aorta due to marked turbulence caused by severe aortic stenosis.

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X QUANGHÔÛ VAN ÑOÄNG MAÏCH CHUÛ

� Nguyeân nhaân thöôøng gaëp nhaát laø sau RAA.

� Caùc nguyeân nhaân khaùc bao goàm:Giang mai,Vieâm noäi taâm maïc nhieãm truøng,Hoäi chöùng Marfan,Chaán thöông,ÑMC boùc taùch,Vieâm khôùp daïng thaáp,Thoaùi hoùa sau gheùp van sinh hoïc.

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� Sinh lyù beänh:Maùu phuït ngöôïc vaøo Thaát (T) trong kyø taâm tröông�Giaõn buoàng thaát (T).Thaát (T) giaõn�Giaõn voøng van 2 laù�Hôû van 2 laù�Giaõn buoàng Nhó (T).

� Moûm tim chuùc xuoáng döôùi vaø ra sau�Bôø (T) tim thoai thoaûi vaø ñænh tim ôû döôùi voøm hoaønh (T).

� Chæ soá T/N > 0,6.

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� ÑMP khoâng to,coù khi nhö loõm vaøo.� ÑMC leân thöôøng khoâng giaõn,neáu ÑMC

leân giaõn roõ,phaûi coi chöøng coù keát hôïp vôùi Heïp van ÑMC.

� Quai ÑMC haàu nhö khoâng thay ñoåi.� Chieáu X quang:ÑMC ñaäp maïnh.

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-Enlarged left ventricle.The apex is displaced downward (large arrow).

-The aorta is slightly prominent but there is no post-stenotic dilatation (small arrows).

AORTIC REGURGITATION

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-Enlarged left ventricle.

-The aorta is slightly prominent but there is no post-stenotic dilatation.


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-Enlarged left ventricle.

-The aorta is slightly prominent but there is no post-stenotic dilatation.


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-Dilated left ventricle.

-Post-stenotic dilatation of the ascending aorta (arrow).

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-Calcified aortic valve (ring of arrowheads).

-Posterior displacement of the dilated left ventricle (row of arrowheads) behind the line of the inferior vena cava (large arrow).

AORTIC STENOSIS & REGURGITATION

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RETROGRADE AORTOGRAM IN AORTIC REGURGITATION

Reflux flow (arrows) in the dilated left ventricle.

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COÄNG HÖÔÛNG TÖØ HÔÛ VAN ÑOÄNG MAÏCH CHUÛ

GRADIENT-ECHO MR

Regurgitant flow from the aortic valve into the left ventricle (arrow)�


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ÑAÏI CÖÔNGBEÄNH VAN ÑOÄNG MAÏCH PHOÅI MAÉC PHAÛI

(ACQUIRED PULMONARY VALVULAR LESIONS)

� Beänh hieám khi ñôn ñoäc vaø hieám khi naëng.

� Beänh coù theå thaáy trong Hoäi chöùng carcinoid.

� Hình aûnh X quang thöôøng keát hôïp toån thöông caùc van tim khaùc.

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ÑAÏI CÖÔNGBEÄNH VAN BA LAÙ MAÉC PHAÛI

(ACQUIRED TRICUSPID LESIONS)

� Töông ñoái gaëp nhieàu hôn beänh van ÑMP maéc phaûi.

� Beänh thöôøng gaëp nhaát sau RAA(Beänh haàu nhö luoân luoân keát hôïp vôùi beänh lyù van 2 laù vaø beänh lyù van ÑMC).

� Caùc nguyeân nhaân khaùc:Vieâm noäi taâm maïc nhieãm truøng,Chaán thöông ngöïc,Böôùu carcinoid…

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X QUANGBEÄNH VAN BA LAÙ MAÉC PHAÛI

� Giaõn buoàng Thaát (P) vaø Nhó (P).� Thöôøng khoâng voâi hoùa van 3 laù.� Giaõn TMC treân,TM azygos.� Daáu hieäu phuï:Gan to,ñoäi voøm hoaønh (P)

leân cao.� Khi Hôû van 3 laù+Heïp van 2 laù�Daáu taùi

phaân phoái vaø ñöôøng Kerley gaàn nhö bieán maát.

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-Huge right atrium.

-Left lower lobe collapse from compression by the dilated heart (arrow).

TRICUSPID STENOSIS AND REGURGITATION.

RIGHT HEART FAILURE.

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-Enlarged right atrium (large arrows).

-Decrease in the pulmonary vasculature.

-Small aortic knob.

-Typical left border of mitral valve disease (small arrow).

-Elevation of the right hemi-diaphragm.

TRICUSPID STENOSIS+AORTIC STENOSIS+MITRAL STENOSIS

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ÖÙNG DUÏNG THÖÏC TEÁ

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KEÁT LUAÄN

� Beänh van tim maéc phaûi phaàn lôùn do RAA.

� Toån thöông thöôøng gaëp nhaát ôû van 2 laù, tieáp ñeán laø van ÑMC.

� Coù theå chæ Heïp ñôn thuaàn,Hôû ñôn thuaàn, coù theå Heïp-Hôû keát hôïp,coù theå toån thöông nhieàu van cuøng moät luùc.

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Documents

3.acquired valvular heart disease