右心衰竭的处理Treatment of Right Heart Failure.ppt

右心衰竭的处理Treatment of Right Heart Failure 中南大学湘雅医院 余再新 湛江 2011－11－28 内 容 慢性右心衰竭的处理 难治性右心衰的处理 急性右心衰竭的处理 概 念 右心衰是指任何原因导致的右心室收缩和/或舒张功能障碍，不足以产生机体所需要的心排出量所出现的临床综合征。 分慢性右心衰竭和急性右心衰竭，急性右心衰竭常见于急性肺栓塞、右室心肌梗死和各种诱因导致的慢性右心衰竭急剧加重。 右心功能衰竭的病残率和死亡率均高于左心衰竭。 目前对于右心功能和右心功能衰竭的研究远远落后于左心功能和左心功能衰竭。 Differences between adult LV and RV While similarities and differences between adult LV and RV have not been well characterized, these 2 ventricles originate from different precursors. Srivastava D. Cell. 2006;126:1037–1048. Effect of Ventricular Contraction Right ventricular Contraction is sequential, starting with the inlet and ending at the infundibulum. Inward movement of the free wall (bellows effect) Contraction of the longitudinal fibers, which shortens the long axis. Traction of the free wall caused by contraction of the LV. (wringing effect) Shortening of the RV is greater longitudinally than radially.In contrast to the LV, twisting and rotational movements do not contribute significantly to RV contraction. This leads to near complete emptying of the RVreduced RVEDPOptimal Venous return. Aortic Pressure and Coronary Blood Flow The response of the RV and LV to experimental increase in afterload. Pathophysiology of failing RV 神经激素的过度激活 已有研究证实自主神经系统、肾素-血管紧张素-醛固酮系统、利钠肽、内皮素系统的过度活化在独立的右心衰竭的发生发展过程中，占有举足轻重的地位。 目前有关神经激素系统的过度激活导致右心衰竭具体机制的研究较少，推测与左心衰竭的发生机制相似，各种活化的神经激素因子作用于心血管系统，引起右心室心肌重构、水钠潴留等，继而导致右心功能不全。 Autonomic nervous system In a dog model of RV failure caused by pulmonary artery banding, demonstrated a decrease in beta-adrenergic receptor density in the stressed RV. Interestingly, the reduced beta-adrenergic receptor density was not limited to the failing ventricle but also occurred in the LV. Bolger AP, et al. Circulation. 2002 In patients with PAH, elevated catecholamine levels were associated with higher pulmonary vascular resistance and lower cardiac index. Endothelin system Endothel