combined valve disease
Introduction
Introduction to combined valvular disease An acquired heart disease is a condition in which two or more valves are diseased, with mitral stenosis and aortic regurgitation being the most common. The valvular lesions can be narrowed or closed. Different types of lesions change the normal blood circulation of the heart, and the left ventricular simple volume load increases, the simple pressure load increases or both coexist. Left ventricular muscle hypertrophy, decreased compliance. basic knowledge The proportion of the disease: the probability of the population is 0.23% Susceptible people: no special people Mode of infection: non-infectious Complications: arrhythmia, acute pulmonary edema, cerebral embolism, superior mesenteric artery embolization, renal artery embolism, hematuria, sudden death, infective endocarditis
Cause
Combined valvular disease etiology
Most of the disease is caused by rheumatic heart disease, and there are also bacterial endocarditis, degeneration, trauma and other causes of valvular disease.
Combined valvular lesions have the following combinations:
1, the same cause involves two or more valves, the most common is rheumatic mitral and aortic valve or other valvular lesions; followed by infective endocarditis can simultaneously invade the mitral valve, aorta Valve or tricuspid valve, pulmonary valve.
2, the lesion originated from a valve, with the development of the disease can affect or involve another valve, leading to relative stenosis or regurgitation, such as rheumatic mitral stenosis can cause pulmonary hypertension, pulmonary hypertension caused by right ventricular pressure overload, causing Right ventricular hypertrophy leads to tricuspid regurgitation.
3, two or more causes involving different valves, such as rheumatic mitral valve disease complicated by infectious aortic valve disease.
In combined valvular disease, mitral stenosis with aortic regurgitation is the most common, with approximately 10% of patients with mitral stenosis associated with severe rheumatic aortic regurgitation, when mitral stenosis with aortic stenosis Mitral stenosis often masks the clinical manifestations of aortic stenosis, but the clinical manifestations of mitral stenosis, such as pulmonary congestion, hemoptysis, atrial fibrillation and systemic embolism, are much more common than simple aortic stenosis. Mitral regurgitation combined with aortic regurgitation is a relatively common combination. At this time, the clinical manifestations of aortic regurgitation are often the main symptom. The presence of mitral regurgitation and aortic stenosis is a dangerous situation. On the one hand, the left atrial decompensation and pulmonary congestion can occur early, on the other hand, the symptoms of insufficient blood supply to the organs can be produced.
Prevention
Combined valvular disease prevention
Combined valvular disease is mainly caused by rheumatic lesions. The timely and effective treatment of rheumatic fever is the key to prevent this disease. For example, rheumatic lesions involve heart valves, pathological changes appear, and affect cardiac function. All patients should undergo valve replacement. The key to success is the maintenance of preoperative cardiac function, and postoperative patients need long-term anticoagulant drugs.
Complication
Combined valvular disease complications Complications, arrhythmia, acute pulmonary edema, cerebral embolism, superior mesenteric artery embolization, renal artery embolism, hematuria, infective endocarditis
Because combined valvular disease is caused by rheumatic heart disease (RHD), its complications are mostly related to rheumatic heart disease:
(1) Atrial fibrillation (Af):
Af is the most common arrhythmia, with an incidence of more than 50%. It is a relatively early complication, sometimes a first-episode illness. It can also be the cause of the first dyspnea or the beginning of limited physical activity. Start early room speed Atrial flutter paroxysmal atrial fibrillation (PAf) chronic persistent Af permanent Af.
Atrial fibrillation: late diastolic, atrial contraction assisted blood loss, left ventricular filling plus the length of diastole,
1 cardiac output is 20%, heart function is reduced to one level, and level II is reduced to level III.
2HR ventricular filling period (diastolic shortening) (increased transvalvular pressure difference) left atrial pressure increased dyspnea acute pulmonary edema, at this time should be satisfied as soon as possible to control the ventricular rate of Af or restore sinus Heart rhythm is essential.
(2) Acute pulmonary edema:
This is a serious complication, especially in the early stage, when the right heart function is good, often in severe physical activity, emotional agitation, infection, pregnancy and childbirth, complicated by AF or other tachyarrhythmia, and induced acute pulmonary edema, manifested as: breathing Difficult; purpura; can not sit flat, sit and breathe; cough pink foamy sputum; double lungs covered with dry and wet rales, if not treated in time, may be fatal.
(3) thromboembolism:
Giant left atrium (>5.5cm); AF: CO is a risk factor for embolism, from left atrium 20% of systemic embolism; 80% of systemic embolism has AF; 1/4 of systemic embolism has repeated and multiple; 2 /3 systemic circulation embolization: cerebral embolism hemiplegia aphasia; extremity arterial embolization limb ischemia, necrosis; superior mesenteric artery embolization small intestinal necrosis, hemorrhagic enteritis; renal artery embolization hematuria; splenic embolism spleen pain, right heart Declined right atrial wall thrombus and / or pelvic vein, deep venous thrombosis of the lower extremity pulmonary embolism; left atrial massive thrombus or pedicle thrombosis block mitral valve mouth sudden death.
(4) Heart failure:
For the late complications is the main cause of death of RHD, heart failure in the incidence of RHD accounted for 50-70%, strenuous activity, pregnancy, active rheumatism is often the predisposing factor.
Right heart failure right heart discharge pulmonary circulation blood volume left atrial pressure decreased dyspnea, the risk of acute pulmonary edema and massive hemoptysis is reduced, this is a protective effect, but the price is heart The blood volume is reduced.
(5) Infective endocarditis:
The incidence rate is 6-10%, which occurs in the early stage of valvular disease. Late valvular calcification or atrial fibrillation is less common. It is more common in MI, AI, and MS alone.
The part of the neoplasm is located downstream of the bloodstream from the high pressure chamber to the low pressure chamber to produce high-speed jets and turbulence, such as: the atrial surface of the valve leaflet of the MI, the ventricular surface of the leaflet of the AI, the right ventricular surface of the VSD, and the blood. The high-speed impact of the heart or the large intima of the large blood vessel is associated with a decrease in lateral pressure and a decrease in intimal perfusion, which is beneficial to microbial deposition and growth.
Infected bacteria are commonly found in Streptococcus mutans (oral), Staphylococcus (skin), Enterococcus and Gram (the digestive tract urinary). Once infective endocarditis occurs, heart failure can be aggravated.
(6) Respiratory infections:
On the basis of pulmonary congestion, it is easy to appear, common, combined with bacterial infection, aggravating heart failure, but pulmonary congestion is not conducive to the growth of TB, and it is difficult to combine TB in the lung.
Symptom
Combined valvular disease symptoms common symptoms palpitations, dyspnea, angina, ascites, shortness of breath
Joint valvular lesions usually occur in two ways:
(1) The same cause involves 2 or more valves, most commonly rheumatic mitral and active valve or other valvular lesions; followed by infective endocarditis can simultaneously invade the mitral valve, aortic valve Or tricuspid valve, pulmonary valve.
(2) The lesion originates from one valve, which may affect or involve another valve as the disease progresses, resulting in relative stenosis or insufficiency. For example, rheumatic mitral stenosis may cause pulmonary hypertension, and pulmonary hypertension may cause excessive pressure in the right ventricle. , causing enlargement of right ventricular hypertrophy and resulting in tricuspid regurgitation.
The main clinical manifestations are as follows:
1, labor palpitations, shortness of breath.
2, angina.
3. Difficulty breathing.
4, mitral valve auscultation area can hear diastolic rumbling or shrinking murmur, the aortic auscultation area can smell systolic or diastolic murmur.
5, liver, liver jugular venous return positive, ascites and so on.
Examine
Combined examination of valvular lesions
(1) Medical examination
A detailed physical examination of the patient can reveal that the patient has physical palpitations, shortness of breath, and auscultation can be heard in the mitral valve auscultation area and diastolic rumbling or systolic murmur, aortic valve auscultation and systolic or Diastolic murmur.
(2) X-ray examination
The performance is more pulmonary blood, the left and right ventricles can be enlarged, and the pulmonary artery segment is convex.
(3) ECG examination
Left and right ventricular hypertrophy, ST segment and T wave abnormalities.
(4) Color Doppler Ultrasound Cardiography (UCG)
The abnormal changes of the diseased valve are shown, and the stenosis is incomplete and the blood flow state is abnormal. The pathological changes caused by the lesions of the two valves are dominant, so the most suitable examination is UCG. The extent of the disease in the valve.
Diagnosis
Diagnosis and diagnosis of combined valvular disease
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
Some diseases are closely related because their clinical manifestations are very similar to those of combined valvular lesions.
(1) The arterial catheter is not closed and severe pulmonary hypertension
Arterial patent ductus arteriosus is a left-to-right shunt congenital heart disease. The blood diverted from the descending aorta to the pulmonary artery is returned to the left atrium through the pulmonary veins, mainly increasing the left anterior preload, causing the left atrium and the left ventricle to expand. Aortic valve, mitral regurgitation, and patent ductus arteriosus develop to severe pulmonary hypertension. The blood flow through the arterial catheter becomes smaller, and the noise becomes lighter or even disappears, especially in rural patients who have not been diagnosed before. Asking about the medical history and conducting a thorough and careful examination may be misdiagnosed as a combined valvular disease.
(2) Aortic valve and mitral regurgitation caused by dry ventricular septal defect
As the condition worsens, the ventricular septal defect of congenital heart disease can progress to aortic coronary valve prolapse and aortic regurgitation. With the enlargement of the left ventricular cavity, mitral regurgitation occurs, especially When the aortic valve covers the ventricular septal defect, it is easily misdiagnosed as a combined valvular disease.
(three) coronary heart disease
Combined valvular disease can be missed with coronary heart disease at the same time. Coronary heart disease itself can also cause valve dysfunction and be misdiagnosed. The clinical manifestations of valvular heart disease with coronary heart disease are mainly the symptoms and signs of valvular disease. Only some patients have angina pectoris. Severe aortic stenosis with angina pectoris, 25% have clear coronary artery disease; and without angina symptoms, can not completely rule out the existence of coronary heart disease, valvular disease with coronary heart disease, left ventricular pressure caused by valvular disease or The volume overload is too heavy, and most patients take oral digoxin treatment, both of which can cause non-specific changes in ECG. Therefore, ECG is of little significance in the diagnosis of coronary heart disease. Coronary angiography is the only clinically diagnosed coronary artery stenosis. Accurate method, due to valvular heart disease combined with coronary heart disease, directly affects the mortality and surgical outcome of valvular surgery. Once valvular disease complicated with coronary heart disease missed diagnosis, coronary heart disease or valvular disease caused by coronary heart disease is misdiagnosed as valvular disease, the consequences are unimaginable The operative mortality rate is extremely high, so it should be analyzed in detail when examining.
