rheumatic mitral stenosis
Introduction
Introduction to rheumatic mitral stenosis Rheumatic mitral stenosis, also known as rheumatic valvular heart disease, is a chronic heart disease left after acute rheumatic fever invades the heart. It is still quite common in China. Rheumatic valvular heart disease is most common with mitral valve, followed by aortic valve, tricuspid valve is rare, pulmonary valve is more rare, chronic rheumatic heart disease can involve several valves. The most common clinically common mitral valve disease, accounting for about 70%, followed by mitral valve with aortic valve disease accounted for about 25%, aortic valve disease alone accounted for 2 to 3%, tricuspid valve or pulmonary artery Valve lesions are often associated with mitral or aortic valve lesions. basic knowledge The proportion of illness: 0.012% Susceptible people: no special people Mode of infection: non-infectious Complications: hypotension, acute heart failure
Cause
Causes of rheumatic mitral stenosis
Rheumatic fever (95%)
Patients with rheumatic valvular heart disease generally have a history of rheumatic fever, such as rheumatic pharyngitis, rheumatoid arthritis, rheumatic myocarditis. The pathogenic microorganism is type A hemolytic streptococcus. Areas with economic backwardness, low living standards and poor sanitation are more likely to develop diseases.
Pathogenesis
Rheumatic valvular heart disease is a chronic heart disease left after acute rheumatic fever invades the heart. Rheumatic fever is an allergic disease, often invading the heart to cause total heart inflammation, involving the pericardium, myocardial and endocardium, and recurrent rheumatic fever. The most serious damage is the endocardium, especially the endocardial tissue of the mitral valve. Long-term recurrent rheumatoid inflammation and mechanical damage caused by blood turbulence and mitral valve disease caused by platelet accumulation mainly include valve junction fusion. Fibrosis thickening, chordae and/or papillary muscle fibrosis shortening, fusion and leaflet calcification, mitral valve leaflet junction fusion occurs first in the former diplomatic and post-internal junctions, and then gradually extends to the central part of the valve orifice, mild The diameter of the stenotic valve is about 1.3cm, the moderate stenosis is 0.8-1.2cm, and the severe stenosis is below 0.8cm. If the junction fusion range is longer than the stenosis, the stenosis is more serious.
Prevention
Rheumatic mitral stenosis prevention
In addition to actively treating rheumatism and preventing damage to the heart, this disease is to prevent the occurrence of rheumatic fever.
Although the cause of rheumatic fever is not fully understood at present, in recent years, it has been fully proved that it has a close relationship with hemolytic streptococcus. Therefore, the following measures are proposed as a recurrence prevention of rheumatic fever activity.
(1) Appropriate activities
Patients after mitral valve surgery should rest for 3 to 6 months, and then according to the specific circumstances of recovery, appropriate increase in activities and labor, activity or labor after heart rate should be controlled to not exceed 15% of normal, such as daily average heart rate during rest 72 times per minute, the activity should not make the heart rate more than 83 beats / min (72 + 0.8 + 82.8), excessive labor, can weaken physical strength, streptococcus flight activities, causing sore throat, cold, disease worsening.
(b)) Drug prevention
For those suspected of rheumatic fever, 1.2 million units of long-acting penicillin G (benzylic-toxin G) are administered intramuscularly once a month.
Complication
Rheumatic mitral stenosis complications Complications, hypotension, acute heart failure
As the mitral valve disease gradually worsens, the left ventricular function is also impaired. Although medical treatment can alleviate the symptoms of heart failure, it can not relieve the mitral and pulmonary vascular obstructive lesions. Most patients without surgery are killed in the age of 50. In pulmonary hypertension, heart failure, atrial fibrillation, systemic embolism or infective endocarditis.
The most common postoperative complications of rheumatic mitral stenosis are the following four:
1. Atrial fibrillation: Atrial fibrillation is the most common complication of mitral closed surgery.
2. Heart failure: The incidence of acute heart failure after surgery is 6.8%, the consequences are serious, accounting for the first cause of surgical death, should be given special attention.
3. Hypotension: Hypotension refers to a condition in which the systolic blood pressure is below 90 mmHg and requires medication. The incidence rate is 5.2%.
4. Embolization.
5. Pericardial incision syndrome: In the past, it was called mitral valve separation syndrome. The clinical manifestation was high fever after 7 to 14 days after operation. It may be accompanied by chest tightness and chest pain. The pericardial area can hear pericardial friction sound. It is an allergic reaction to the blood in the pericardium. The administration of hormones can be resolved in a few days. Since the pericardial drainage and the routine administration of hormones after surgery, this kind of complications rarely occurs.
Symptom
Symptoms of rheumatic mitral stenosis Common symptoms Short-term diastolic tremor dysfunction apex 1st heart sound hyperthyroidism Heart tremor dyspnea systolic murmur hemoptysis
[clinical manifestations]
The mitral stenosis cases are mostly around 30 years old when they seek medical treatment. As the mitral valve disease gradually worsens, the left ventricular function is also impaired. After 10 to 15 years after onset, the cardiac function is often reduced to 3 to 4, although the medical treatment is It can alleviate the symptoms of heart failure, but can not relieve the mitral and pulmonary vascular obstructive lesions. Most patients who have not undergone surgery have died of pulmonary hypertension, heart failure, atrial fibrillation, systemic embolism or infective endocarditis in the age of 50. .
About 50% of patients with rheumatic mitral stenosis have a history of rheumatic fever or migratory polyarthritis. The symptoms of mitral stenosis are generally at least 10 years from rheumatic fever. The majority of cases are 20 years old. Above, the clinical symptoms of mitral stenosis progress slowly, and the initial symptoms are dyspnea caused by stagnation of the stenosis of the mouth. Initially, after a heavy physical labor, there is an air urgency, and then moderate and mild labor also occurs after anxious, in manual labor. Respiratory infection, arousal or atrial fibrillation, sitting breathing, paroxysmal nocturnal dyspnea and pulmonary edema, cough is also a common symptom. After labor, it occurs more often during sleep and bronchitis, and the sputum is white. Mucus, some cases show similar asthma attacks, palpitations, paroxysmal atrial fibrillation, fatigue, fatigue, dizziness and other symptoms, patients may have repeated hemoptysis, the number of bleeding varies, bronchial mucosal bleeding leads to sputum Bloodshot, acute pulmonary edema hemorrhage is pink foamy mucus, varicose bronchial vein rupture can occur a lot of hemoptysis, advanced cases can be presented Hepatomegaly, ascites, subcutaneous edema and other symptoms of right heart failure, a few patients clinically first symptoms are systemic embolism.
Examine
Rheumatic mitral stenosis
1. Chest X-ray examination: in the early cases, the anterior chest X-ray film can be seen without abnormal signs. The left atrium is enlarged when the valve is obviously narrow, and the dense double shadow of the left and right atrium overlaps on the right side of the heart shadow. , left atrial appendage, right ventricle and common pulmonary artery enlargement, aortic arch reduction, pulmonary conus protrusion, pulmonary artery branch widened, hilar shadow deepened, normal depression between left ventricle and aortic ball disappeared, heart shadow left edge straight, long-term In the case of pulmonary stagnation, the scattered speckled shadows of hemosiderin deposition can be seen in the lung field, and the thin horizontal horizontal line (Kerley B line) with increased density due to long-term pulmonary lymph node deposition can be seen in the lower part of the lung field. Lateral or oblique X-ray examination of the barium meal can show the enlarged left atrium compression of the esophagus and the esophagus moved to the posterior, the enlarged left atrium can also raise the left main bronchus, and the angle of the main bronchus on both sides increases. In the case of simple mitral stenosis, the left ventricle should not be enlarged. If the left ventricle is enlarged, it should be highly suspected to be accompanied by mitral regurgitation.
2. Electrocardiogram examination: ECG of patients with mild mitral stenosis may have no abnormal signs. Left atrial hypertrophy showed P-wave broadening and incision on the electrocardiogram and increased biphasic P wave in the right chest lead. Pulmonary artery High-pressure cases present signs of right-axis and right ventricular hypertrophy and strain, and patients with long-term disease often have atrial fibrillation.
3. Cardiac catheter and cardiovascular angiography: mitral stenosis cases do not require routine cardiac catheterization, but multi-valvular heart catheterization and cardiovascular angiography can help to determine whether other valves have lesions and their severity, right Cardiac catheterization can measure right ventricular, pulmonary and pulmonary microvascular pressure, pulmonary circulation resistance, cardiac output index and calculated valve area, mitral stenosis cases, right ventricle, pulmonary artery, pulmonary microvascular pressure increased, pulmonary circulation resistance increased, heart The blood output index decreased, left atrial catheterization can measure left atrial pressure, mitral valve transvalvular pressure difference, mitral stenosis case mitral valve transvalvular pressure difference exceeds 0.7kPa (5mmHg), early mitral stenosis cases rest The pressure difference may be normal only 0.3 ~ 0.4kPa (2 ~ 3mmHg), can quickly increase to more than 1.3kPa (10mmHg) after exercise, selective left ventricular angiography can determine the presence or absence of mitral regurgitation and determine left ventricular contraction Function, aortic angiography can confirm the presence or absence of aortic regurgitation.
4. Echocardiography: M-mode echocardiography showed left atrium, right ventricle enlargement, mitral anterior leaflet curve diastolic E peak slowly decreased, and the BE wave decreased slowly, showing a wall-like image, due to At the junction of the valve, the anterior leaflet and the posterior leaflet move in the same direction. The echocardiography of the cut surface can show the thickening of the valve, the mobility is limited, the shape is irregular, the valve is narrow, and the fashion can show the thickening of the chordae. Echocardiography can still check the left atrial appendage, whether there is a thrombus in the left atrium, the use of esophageal probe to examine the left atrial appendage, the left atrial thrombus, the diagnosis is more reliable.
Diagnosis
Diagnosis and diagnosis of rheumatic mitral stenosis
diagnosis
Diagnosing mitral stenosis is generally not difficult, and typical simple mitral stenosis can be clearly diagnosed based on medical history and signs.
Differential diagnosis
Typical diagnosis of simple mitral stenosis is generally not difficult. Clinical manifestations and cardiac signs are very similar to rheumatic mitral stenosis. Left atrial myxoma. Heart murmur in left atrial myxoma may change loudness or disappear with body position. Echocardiography can show that the cloud-like echogenic reflection of the tumor in the left atrium enters the mitral valve or the left ventricle during diastole, and is included in the left atrium during systole. It is of great value for definite diagnosis and is considered for surgical treatment. In patients with mitral stenosis, it is necessary to find out whether mitral regurgitation and other valves are also present and the severity of the lesion. Selective coronary angiography should be performed in patients over 40 years old to understand the presence or absence of coronary artery disease. Obstructive lesions.
