tricuspid stenosis
Introduction
Introduction to tricuspid stenosis Tricuspidstenosis is more common in women, most of which are caused by rheumatic fever. Similar to mitral stenosis, the pathological changes of rheumatic tricuspid stenosis show that the chordae tendrils are fused and shortened, and the tip of the leaflets is fused. A diaphragm-like aperture. Tricuspid stenosis may be associated with tricuspid regurgitation or with any other valve lesion. The right atrium is obviously enlarged, the atrial wall is thickened, and signs of severe visceral blood stasis such as liver and splenomegaly can also occur. basic knowledge The proportion of the disease: the incidence rate of middle-aged and elderly people over 50 years old is 0.03%--0.07% Susceptible people: more common in women Mode of infection: non-infectious Complications: pulmonary embolism, pulmonary embolism and pulmonary infarction
Cause
Cause of tricuspid stenosis
(1) Causes of the disease
Rheumatic tricuspid stenosis, sequelae of rheumatic fever, pathological changes of rheumatic tricuspid stenosis and mitral stenosis, mainly at the junction of the valve leaflet, thickening of the leaflet edge and thickening and shortening of the chordae, etc. Causes the area of the tricuspid orifice to shrink.
(two) pathogenesis
1. Pathological anatomy The pathological changes of rheumatic tricuspid stenosis are similar to those of mitral stenosis. It can be seen that the valve leaf is thickened, the margin of the valve is adhered, and the chordae tendine is thickened and shortened to form a diaphragm-like pore.
Tricuspid stenosis is more common in women. It can be combined with tricuspid regurgitation or any other valvular lesions. The right atrium is obviously enlarged, the atrial wall is thickened, and severe visceral congestion such as liver and spleen may occur.
2. Pathophysiology Normal tricuspid valve chamber, the pressure gradient of the chamber is small. When the tricuspid stenosis is present, the pressure gradient of the chamber is >0.67kPa (5mmHg), and systemic congestion can occur due to the volume of the vena cava system. Large, low resistance, has a considerable buffering effect on the right atrial pressure, so the pressure generated by right atrial congestion is generally less than 2.0kPa (15mmHg), but long-term tricuspid stenosis can enlarge the right atrium And increased pressure, causing vena cava reflow disorders, further leading to increased venous pressure, such as jugular vein engorgement, hepatomegaly and lower extremity edema, and in addition, due to insufficient right ventricular diastolic filling, the right ventricular cardiac output is reduced, thus It can reduce the degree of pulmonary congestion, so tricuspid stenosis has a protective effect on the pulmonary vascular bed of patients with mitral stenosis. If it is simple tricuspid stenosis, it will return to the left atrium due to the decrease of pulmonary circulation. The left ventricular blood volume is also reduced, which can reduce the left heart discharge.
Prevention
Tricuspid stenosis prevention
Rheumatic heart disease can be effectively prevented. The main measures include:
1. Effective primary and secondary prevention
(1) Effective primary prevention: refers to the prevention of the first episode of rheumatic fever, the key is early diagnosis and treatment of methyl chain tonsillitis, the preferred drug for penicillin, Huang Zhendong scholars to carry out group rheumatic fever level and prevention research, early discovery Chain-type tonsil pharyngitis and early drug intervention, the results show that the intervention of half a year can reduce the number of cases of methyl-chain tonsil pharyngitis in the population by as much as 95.4% to 100%, reaching the primary prevention effect of group rheumatic fever.
(2) Active secondary prevention: refers to prevention of recurrence of rheumatic fever, which is essential for patients who have suffered from heart-warming or existing rheumatism. Rheumatic fever recurrence is most common in the first 5 years after the first episode, and recurrence after 5 years. Only 5%, the prevention target mainly refers to patients with rheumatic fever with a clear history of rheumatic fever and/or diagnosis. For patients with initial rheumatic fever without carditis, prevent 5 years after the last episode of rheumatic fever, at least To 18 to 20 years old; if there is carditis, it should be extended or even life. For patients with chronic rheumatic valvular disease, the prevention time should be long, usually until 50 years old or even for life; even PBMV (percutaneous mitral balloon) Surgery is still necessary to prevent rheumatism after surgery.
2. Prevention measures
(1) Prevention of rheumatic fever: It is the key. Individual use should be used when using drugs. Injection of penicillin should be especially alert to the occurrence of anaphylactic shock. When the clinic is injected, there should be corresponding first aid facilities.
(2) Avoid crowding: especially in the family bedroom and school classroom, keep well ventilated, not suitable for crowded places, because of the rapid spread of streptococcus between people, may increase the chance of infection.
(3) Reasonable arrangement of life and work: pay attention to work and rest, avoid mental and physical overwork and bad stimulation, emotional agitation, lack of sleep, etc., quit smoking and alcohol, avoid overeating and overweight, heart dysfunction should avoid severe Exercise and sudden exertion, such as running, swimming, lifting weights, driving, etc., heart function level I can basically live a normal life, but should not participate in competitive physical activity; heart function level II should avoid medium and heavy physical labor, such as There is no time to rest and treatment, female patients with heart function I ~ II can consider pregnancy, but need to be closely observed during pregnancy, heart function level III or above should not be pregnant.
(4) Regular examination: The main target is the cardiac function compensator, and patients with grade II or above should actively undergo interventional and surgical treatment.
(5) Master the self-care ability of rheumatic fever and rheumatic heart disease: Patients with rheumatic heart disease should learn some simple prevention knowledge and skills, such as measuring body temperature, counting pulse, listening to heart rate, measuring blood pressure, measuring urine volume, weighing body, low-salt diet. Etc. And familiar with major clinical manifestations such as rheumatic activity, heart failure, arterial embolism and infective endocarditis.
(6) Prevention of complications and comorbidities: the focus is on prevention of heart failure, low-salt diet in patients with rheumatic heart disease, avoiding excessive exertion, work fatigue, secondary infection, arrhythmia are important, for aortic valve disease or prosthetic valve replacement Patients, if necessary, often use antibiotics to prevent infective endocarditis.
Complication
Tricuspid stenosis complications Complications pulmonary embolism pulmonary embolism and pulmonary infarction
Tricuspid stenosis is almost all the consequences of rheumatic fever, and both are complicated by mitral stenosis and or aortic valve disease. Like mitral stenosis, patients with rheumatic tricuspid stenosis are often accompanied by different degrees of tricuspid The valvular insufficiency, the right atrium of the patients with tricuspid stenosis is significantly enlarged, the right atrial wall is thickened, and there is severe systemic congestion, the liver and spleen are enlarged, and the tricuspid stenosis is almost always associated with the mitral valve or aorta. The presence of valvular lesions indicates that the patient's rheumatic inflammation is more severe and extensive than those with only mitral valve disease and/or aortic valve disease. Therefore, the prognosis is generally poor, such as no surgical treatment, the patient finally Can die of progressive right heart failure, pulmonary infarction or pulmonary embolism, simple tricuspid stenosis is extremely rare, although the patient has obvious venous system congestion, but the asymptomatic period can last for many years.
Symptom
Symptoms of tricuspid stenosis Common symptoms Fatigue of jugular vein dyspnea, lower extremity edema, diastolic tremor, gastrointestinal congestion, nausea
Symptom
(1) Simple tricuspid stenosis can cause right atrial failure and signs of systemic congestion.
1 fatigue: the blood flow through the tricuspid valve is reduced, leading to a decrease in cardiac output.
2 There is pulsating discomfort in the neck: the jugular vein is obviously pulsating.
3 gastrointestinal congestion: loss of appetite, nausea, vomiting or belching.
(2) Tricuspid stenosis and mitral valve disease at the same time: the presence of tricuspid stenosis can alleviate the symptoms of pulmonary congestion caused by mitral stenosis, so when there is mitral stenosis and difficulty breathing (labor or night Array) If the dyspnea is not obvious, it suggests the possibility of tricuspid stenosis.
2. Signs
(1) The heart sounds are shifted to the right.
(2) Some patients may have diastolic fine tremor in the tricuspid valve area.
(3) Auscultation:
1 Tricuspid valve diastolic murmur: heard a weaker loudness between the 4th and 5th intercostals of the sternal border to the midline of the sternum, low frequency and gentle diastolic, late rumbling-like murmur, no obvious enhancement before systole, murmur In the deep inspiratory enhancement, the Carvallo sign, due to increased blood flow to the right heart during inhalation, resulting in increased blood flow rate and blood flow through the narrow tricuspid valve, while mitral stenosis noise during inhalation Not enhanced, but increased at the end of deep exhalation, due to increased pulmonary blood circulation to the left heart.
2 tricuspid valve area can be heard tricuspid valve open sound: 0.04 ~ 0.06s after S2, enhanced when inhaling.
3 Tricuspid valve area S1 can be hyperthyroidized: When the valve is significantly calcified or the activity is significantly reduced, S1 can not be hyperthyroidized.
(4) A large jugular vein a wave: due to the strong contraction of the right atrium to the tricuspid valve of the sinus rhythm; when the atrial fibrillation shows a significant V wave in the jugular vein, in the case of severe pulmonary hypertension and right ventricular hypertrophy Because the compliance of the right ventricle is reduced, the blood flow filling resistance of the right atrium returning to the right ventricle is increased, and the a-wave of the jugular vein is increased. When there is no right ventricular hypertrophy in the clinic and there is a large jugular wave a wave, it is Characteristic signs of tricuspid stenosis.
(5) jugular vein engorgement: liver enlargement, positive liver neck reflow test, lower extremity edema, and even peripheral hair cyanosis.
(6) Rheumatic tricuspid stenosis: When multiple valvular lesions are present, both mitral and/or aortic valve murmurs may be present.
Examine
Tricuspid stenosis examination
1. X-ray examination of simple tricuspid stenosis, the right atrium significantly enlarged with superior vena cava widening, but the right ventricle did not increase, the pulmonary artery did not expand, pulmonary blood decreased.
2. ECG II, III, aVF lead P wave high tip, often > 0.25 mV, suggesting right atrial hypertrophy, such as combined mitral stenosis may have right ventricular hypertrophy and electrical axis right deviation.
3. The jugular vein beat map has a huge a wave.
4. Echocardiography (UCG)
(1) M-type and two-dimensional UCG: tricuspid leaf thickening, echo enhancement, activity stiffness, open restriction, right atrial enlargement, upper and inferior vena cava and hepatic vein widening, M-type motor curve EF, slope slowed, The leaflets move in the same direction.
(2) Doppler UCG: sampling at the infarction of the right ventricle of the tricuspid valve, can detect the high-speed jet spectrum in the diastolic period, and can measure the pressure difference across the flap. The color Doppler can display colorful on the two-dimensional plane. Inlaid jet beam.
5. Cardiac catheterization is an important diagnostic basis for the treatment of tricuspid valve separation. The average diastolic pressure gradient is 0.27kPa (2mmHg), which means the presence of tricuspid stenosis. When performing cardiac catheterization, it must be recorded synchronously. The pressure of the atria and the right ventricle can correctly determine the pressure gradient. Patients with atrial fibrillation or low cardiac output under physiological conditions can change the correctness of the transvalvular pressure gradient measurement. Right atrial angiography can be seen right. Ventricular filling is delayed, and tricuspid valve thickening and limited mobility are seen, as well as thickening of the right atrial wall and enlarged right atrial diameter.
Diagnosis
Diagnosis and differentiation of tricuspid stenosis
diagnosis
According to the typical murmur, right atrial enlargement and symptoms and signs of systemic congestion, diagnosis can be made generally. For patients with difficult diagnosis, right heart catheterization can be performed. If the tricuspid valve has an average transvalvular pressure difference of 0.27 kPa (2 mmHg) or more. , can be diagnosed as tricuspid stenosis.
Differential diagnosis
Should be noted with the right atrial myxoma, constrictive pericarditis and other diseases.
