Stenosis of the mitral valve ( mitral stenosis ) - Causes, Symptoms and Treatment .MF .
Symptoms of stenosis, mitral valve
treatment of mitral stenosis
mitral valve occupy a leading position among all the acquired heart defects, the most common combination of stenosis (narrowing) and failure (incompleteclosing of the valves) and isolated mitral stenosis occurs in about 30% of the defects of the valve.
The mitral valve is a connective tissue formation, located on the border of the left atrium and the left ventricle.It consists of two thin and movable wings (front and back), the main function of which is as follows: when the blood comes from the atrium into the ventricle, flaps diverge, letting blood flow, as well as the blood flows from the ventricle into the aorta, shutters are closed, preventingthe return of blood flow in the atrium.Ideally, the leaflet must be fully occlude, blocking the left atrioventricular opening (between the atrium and ventricle).The area of the latter in adults is approximately 4 - 6 square ce
If there is a replacement of normal connective scar tissue on the valve, it develops adhesions and adhesions between the doors or in the surrounding valve fibrous ring.Such a pathological condition called mitral valve stenosis (synonym - stenosis of the left atrioventricular orifice).
mitral stenosis - a disease related to a group of acquired heart disease and is characterized by the following features:
- is caused by an organic lesion of the connective tissue of the valve leaflets, for example, inflammation in the heart of rheumatism, bacterial endocarditis;
- as a result of scarring formed narrowing of the opening between the atria and ventricles, which creates an obstacle movement of blood from the atrium into the ventricle;
- the obstacle increases the pressure in the left atrium with its hypertrophy (thickening of the walls) and reduced blood into the left ventricle ejection and therefore to the aorta;i.e. developing hemodynamic disorders (blood flow in the heart and in the whole organism);
- without surgery comes the wear of the heart muscle and its inability to ensure the circulation of blood throughout the body, which leads to disruption of the blood supply and nutrition of all body tissues.
Causes of mitral valve stenosis
In most cases, the cause of mitral stenosis, as well as other acquired heart disease is rheumatism (acute rheumatic fever) with the development of rheumatic heart disease - an inflammation of the heart muscle and connective tissue.
symptoms of mitral stenosis
severity of clinical signs of stenosis varies according to the stage of the process (in Russian common classification Bakulev).
In compensation stage clinical symptoms are not observed due to the fact that heart and body adapt to the existing anatomical abnormalities using compensatory mechanisms.This stage can last for many years, especially if the narrowing of the valve ring is not very large - approximately 3 cm 2 or more.
In stage subcompensation as the progressive narrowing of the atrioventricular openings adaptive mechanisms can not cope with the increased load on the heart.There are the first symptoms - shortness of breath on exertion, pain in the heart and in the interscapular region to the left with a load or without a sense of disruption in heart and heart palpitations, violet or blue coloration of the skin fingertips, ears, cheeks (cyanosis), chilliness,extremities cold snap.It may also occur atrial fibrillation.
In decompensated comes pronounced depletion of the heart muscle, is formed stagnation of blood in the lungs first, and then in all the organs and tissues of the body.Shortness of breath takes a permanent nature, the patient can breathe only in the half-sitting position (orthopnea), often a carrier of life threatening condition - pulmonary edema.
Later stage severe decompensation joined cough, coughing up blood, swelling of legs and feet, abdominal enlargement due to intraluminal edema, pain in the right upper quadrant due to the blood supply to the liver (may develop cardiac cirrhosis).This step may even be reversed during drug therapy.
Next terminally (stage of irreversible changes in the heart muscle and the body), blood pressure decreases, there is a whole body edema (anasarca).In connection with the violation of the metabolic processes in the heart and all internal organs comes death.
Diagnosis of mitral valve stenosis
diagnosis of mitral stenosis is established based on the following data.
1. Clinical examination.Noteworthy pale skin in conjunction with cyanotic coloration of the cheeks ( "mitral blush"), swelling of legs and feet, abdominal enlargement.Determined by low blood pressure, combined with a weak frequent pulse.When auscultation of the chest (auscultation) reveals abnormal noises and tones (called "rhythm of quail"), due to the blood flow through the narrowed opening, wheezing in the lungs.When palpation of the abdomen (palpation) is determined by an increase in the liver.
2. Laboratory examination methods.In the clinical analysis of blood can detect increasing levels of leukocytes (white blood cells) due to active rheumatic process in the body, the violation of the blood coagulation system.The general analysis of urine appear abnormal performance, indicating impaired renal function (protein, white blood cells, etc.).In the biochemical analysis of blood are determined by performance of the liver and kidney function (bilirubin, urea, creatinine, etc.).Also, methods of immunological studies of blood may reveal changes characteristic of rheumatic fever (C - reactive protein, antistreptolysin, antistreptokinaza etc.).
3. Instrumental methods.
- during the ECG recorded changes characteristic of hypertrophy of the left atrium and the right ventricle, cardiac arrhythmias.
- ECG monitoring allows to identify possible cardiac arrhythmias during normal everyday activities that are not registered during a single ECG at rest.
- radiographs of the chest are determined congestion in the lungs, heart change configuration due to the expansion of its cameras.
- echocardiography (ultrasound of the heart) is carried out to visualize internal structures of the heart, reveals a change in thickness and mobility of the valve leaflets, narrowing its aperture, it allows you to measure the area of narrowing.Also, when ECHO - CG doctor determines the degree of hemodynamic disorders (increased pressure in the left atrium, hypertrophy and dilatation (widening) of the left atrium and right ventricle), assesses the degree of impairment of blood flow from the left ventricle into the aorta (ejection fraction, stroke volume).
By area atrioventricular openings distinguish slight stenosis (more than 3 square cm..), Moderate stenosis (2.0 -. 2.9 square cm.), Severe stenosis (1.0 -. 1.9 square cm.), Critical stenosis (less than 1.0 sq cm.)..The measurement of this parameter is important in terms of the patient, in particular, the definition of surgical tactics as stenosis with an area less than 1.5 square meters.cm. is a direct indication for surgery.
- before surgical treatment, or in cases of unclear diagnosis can be displayed catheterization of heart cavities, in which the heart chamber is measured and the pressure is determined by the pressure difference in the left atrium and ventricle.
on images obtained by echocardiography, visible thickened mitral valve (mitral valves)
treatment of stenosis of the mitral valve
doing tactics with the choice of method of treatment (medication, surgery or a combination thereof) is determined individually for each patientdepending on the degree of stenosis and clinical stage of the disease.
So, in the absence of clinical manifestations and the degree of narrowing of the left atrioventricular opening of more than 3 square meters of stage 1 (compensation).. See operation is not shown, and drug treatment aimed at the prevention of stagnation of blood vessels in the lungs (diuretics, modification of long-acting nitroglycerin - nitrosorbid, monocinque).
Stages 2 and 3 (subcompensation and initial manifestations of decompensation), especially in combination with the degree of stenosis of less than 1.5 square meters.cm. is an indication for surgical treatment with a constant intake of drugs.
In step 4 (expressed decompensation) surgery can prolong the life of the patient, but not for long, however, as a rule, in this stage, surgical treatment is not applied from - the high degree of post-operative risk.
In stage 5 (the terminal), the operation is contraindicated due to pronounced hemodynamic disorders and changes in the internal organs, therefore, applies only drug treatment for palliation (alleviate patient suffering, as far as possible).
Drug therapy mitral valve stenosis is reduced to the appointment of the following groups of drugs:
- cardiac glycosides (Korglikon, strofantin, digitoxin, etc.) are used in patients with impaired contractility of the right ventricle, as well as when the patient permanent form of atrial fibrillation.
- B - blockers (carvedilol, bisoprolol, nebilet, etc.) are used for the purpose of shortening rate in the event of paroxysms (attacks) atrial fibrillation or its permanent shape.
- Diuretics (diuretics - indapamide, veroshpiron, furosemide, spironolactone and others) need to "unload" the pulmonary circulation (pulmonary vessels) and reduce congestion in the internal organs.
- ACE inhibitors (fosinopril, ramipril, lisinopril, captopril, etc.) and angiotensin receptor blockers 11 (valsartan, losartan, etc.) have kardiprotektornymi properties - protects the heart cells from the damaging effects of various substances (eg, lipid peroxidation products), producedin many, including cardiac diseases.
- nitrates (nitroglycerin, nitrosorbid, kardiket retard monocinque, etc.) are used as peripheral vazodilalatorov, ie, dilates blood vessels in the periphery of the body, which directs blood from the pulmonary vessels and thus reduce the severity of dyspnea.
- antiplatelet agents and anticoagulants (tromboAss, cardiomagnil, aspirin, heparin, etc.) are used to prevent the formation of blood clots in the heart and blood vessels, especially for atrial fibrillation in the postoperative period.
- Antibiotics (penicillin), and anti-inflammatory drugs (ibuprofen, diclofenac, nimesulide, etc) are required during the acute phase of rheumatic fever and rheumatic at repeated attacks.
exemplary treatment regimen a patient with mitral stenosis with minimal clinical manifestations, without atrial fibrillation (taking medication daily for a long time, with a possible replacement for drug or correction of its dosage your doctor depending on the severity of symptoms):
- noliprel A Fort 5mg / 1.25 mg (5 mg perindopril + indapamide 1. 25 mg) in the morning,
- Concor (bisoprolol) 10 mg 1 time per day in the morning,
- tromboAss 100 mg per meal after meal,
- Nitromintum 1 - 2 doses under the tonguepain in the heart or shortness of breath,
- monocinque 20 mg 2 times a day - 2 weeks, then 10 mg nitrosorbid 20 minutes before exercise.
to surgical treatments include:
- balloon valvuloplasty - through the vessels of the heart fed probe with a miniature balloon on the end that is inflated at the time of it through the atrioventricular opening, and disconnects fusion of the valve leaflets,
- open commissurotomy - surgery is performed in the openthe heart of the implementation of the access to the mitral valve and its dissection of adhesions,
- mitral valve - often used in combination valve stenosis and insufficiency and carried out by replacing its valve with an artificial (mechanical or biological implant).
Contraindications to surgery:
- stage severe decompensation (ejection fraction less than 20%) and end-stage flow blemish;
- acute infectious diseases;
- general somatic diseases in the stage of decompensation (asthma, diabetes, etc.)
- acute myocardial infarction and other acute diseases of the circulatory system (hypertensive crisis, stroke, first encountered complex arrhythmias, etc.).
Lifestyle mitral stenosis
for patients with this disease is required to observe the following guidelines: well and eat right, limit the amount of fluid intake and salt, to establish an adequate work and rest, sleep well, limit physical activity and eliminate stressful situations,a long time to be outdoors.
pregnant woman need time to get registered in antenatal clinics to address the issue of prolongation of pregnancy and the choice of delivery method (usually by cesarean section).Compensated vice pregnancy proceeds normally, but the hemodynamic expressed violations of pregnancy is contraindicated.
Complications of untreated
Without treatment, there comes the inevitable progression of hemodynamic disorders expressed stagnation in the lungs and other organs, leading to the development of complications and death.Complications of this disease are such as pulmonary embolism (especially in patients with atrial fibrillation), pulmonary edema, pulmonary hemorrhage, acute heart failure.
Complications of surgery
both early and late postoperative periods, as there is a possibility of complications:
- infective endocarditis (inflammation of bacterial growth on the leaf valves, including biological and artificial);
- blood clots as a result of a mechanical prosthesis with the development of thromboembolism - a blood clot separation and release it into the blood vessels of lungs, brain, abdomen;
- degeneration (destruction) of the artificial bioklapana with the re-development of hemodynamic disturbances.
doctor Tactics reduced to a regular survey of patients by echocardiography, the control of blood coagulation system, life purpose anticoagulants and antiplatelet agents (clopidogrel, warfarin, dipyridamole, chimes, aspirin, etc.), antibiotic therapy in infectious diseases, abdominal operations, carrying out the minimal treatment -diagnostic procedures in gynecology, urology, dentistry and so on. d.
mitral stenosis treatment without adverse, since death is the outcome of the disease.The average age of patients with such a defect is 45 - 50 years.It is essential to extend the life and improve the quality of heart surgery allows the treatment (as a method of radical correction method of anatomical and functional changes) in conjunction with a regular intake of drugs.
therapists Sazykina OJ