Boudoulas H, Vavuranakis M, Wooley C F
Ohio State University, Division of Cardiology, Columbus 43210.
J Heart Valve Dis. 1994 Sep;3(5):516-26.
The many changes in classification of cardiovascular disease during the twentieth century reflect changing etiology of diseases, clinical comprehension and technological advances. In particular, the etiology of valvular heart disease has changed dramatically in the last five decades. The significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of valvular disease are responsible for the metamorphosis in the etiology of valvular disorders. Valvular heart disease can be classified as follows: 1) Heritable-congenital causes of valvular heart disease e.g., floppy mitral valve with mitral valve prolapse, bicuspid aortic valve, and the Marfan syndrome; 2) Inflammatory-immunologic causes such as rheumatic fever, acquired immune deficiency syndrome, endocardial proliferative disorders, and antiphospolipid syndrome; 3) Myocardial dysfunction-ischemic cardiomyopathy, dilated or hypertrophic cardiomyopathy-resulting in valvular heart disease; 4) Diseases and disorders of other organs as causes of valvular heart disease, e.g., chronic renal failure and carcinoid heart disease; 5) Valvular heart disease related to aging: calcific aortic stenosis and mitral annular calcification; 6) Valvular disease following interventions such as valvuloplasty, valve reconstructive surgery and valve replacement; and 7) Valvular disease related to drugs and physical agents, such as chronic ergotamine use, radiation therapy and trauma. In clinical practice the most common causes of mitral regurgitation are floppy mitral valve with mitral valve prolapse, ischemic heart disease, dilated cardiomyopathy and mitral annular calcification, while the most common cause of mitral stenosis is rheumatic fever. The most common causes of isolated aortic regurgitation are bicuspid aortic valve and floppy aortic valve, while the most common causes of isolated aortic stenosis are related to the bicuspid aortic valve and the development of calcific senile aortic stenosis. The most common causes of tricuspid regurgitation are dilated cardiomyopathy, ischemic cardiomyopathy, floppy tricuspid valve with tricuspid valve prolapse and infectious endocarditis. Combined mitral and tricuspid regurgitation occur with heritable connective tissue disorders, dilated or ischemic cardiomyopathy, while the most common cause of mitral stenosis plus aortic regurgitation is rheumatic fever. Statistics obtained from cardiac surgery and necropsy may underestimate the true incidence of certain valvular diseases by selection bias. This is particularly so with valvular disease associated with significant ventricular dysfunction, or in the elderly who may not be surgical candidates, or in cases where the valvular disease is not severe enough to require surgical intervention. Recent advances in hemodynamic and imaging technology allow clinicians to define valvular structure and function and to accurately classify valvular heart disease in clinical practice.
二十世纪心血管疾病分类的诸多变化反映了疾病病因、临床认知及技术进步的改变。特别是在过去五十年中，瓣膜性心脏病的病因发生了显著变化。急性风湿热及其后遗症的大幅减少，以及对瓣膜病非风湿性病因的认识，是瓣膜性疾病病因发生转变的原因。瓣膜性心脏病可分类如下：1）遗传性 - 先天性瓣膜性心脏病病因，如二尖瓣脱垂伴二尖瓣脱垂、二叶式主动脉瓣以及马方综合征；2）炎症 - 免疫性病因，如风湿热、获得性免疫缺陷综合征、心内膜增殖性疾病以及抗磷脂综合征；3）心肌功能障碍 - 缺血性心肌病、扩张型或肥厚型心肌病导致的瓣膜性心脏病；4）其他器官的疾病和紊乱作为瓣膜性心脏病的病因，如慢性肾衰竭和类癌性心脏病；5）与衰老相关的瓣膜性心脏病：钙化性主动脉瓣狭窄和二尖瓣环钙化；6）瓣膜成形术、瓣膜重建手术和瓣膜置换等干预后出现的瓣膜性疾病；7）与药物和物理因素相关的瓣膜性疾病，如长期使用麦角胺、放射治疗和创伤。在临床实践中，二尖瓣反流最常见的病因是二尖瓣脱垂伴二尖瓣脱垂、缺血性心脏病、扩张型心肌病和二尖瓣环钙化，而二尖瓣狭窄最常见的病因是风湿热。孤立性主动脉反流最常见的病因是二叶式主动脉瓣和主动脉瓣脱垂，而孤立性主动脉狭窄最常见的病因与二叶式主动脉瓣和钙化性老年主动脉狭窄的发展有关。三尖瓣反流最常见的病因是扩张型心肌病、缺血性心肌病、三尖瓣脱垂伴三尖瓣脱垂和感染性心内膜炎。二尖瓣和三尖瓣联合反流与遗传性结缔组织疾病、扩张型或缺血性心肌病有关，而二尖瓣狭窄加主动脉反流最常见的病因是风湿热。从心脏手术和尸检获得的统计数据可能因选择偏倚而低估某些瓣膜性疾病的真实发病率。对于伴有严重心室功能障碍的瓣膜性疾病、可能不适合手术的老年人，或瓣膜性疾病严重程度不足以需要手术干预的情况尤其如此。血流动力学和成像技术的最新进展使临床医生能够在临床实践中定义瓣膜结构和功能，并准确分类瓣膜性心脏病。
