Mitral and aortic valve disorders
Introduction
Introduction to mitral and aortic valve disorders Multivalvular heart disease (multivalvular heart disease) refers to multiple valve disease when it invades two or more valves at the same time, especially in rheumatic heart disease. Different combinations of polyvalvular diseases can produce different hemodynamic disorders. And clinical manifestations, mitral and aortic valve double lesions are the most common polyvalvular disease. basic knowledge The proportion of sickness: 0.001%-0.002% (incidence rate is about 0.001%-0.002%, more common in middle-aged and elderly patients) Susceptible people: no special people Mode of infection: non-infectious Complications: arrhythmia pulmonary hypertension
Cause
Causes of mitral and aortic valve disorders
(1) Causes of the disease
The causes of mitral and aortic double lesions can be divided into rheumatoid and non-rheumatic categories, of which rheumatism is the most common, especially in Africa, India, South America and many developing countries including China. Degenerative changes and infective endocarditis are common in non-rheumatic causes, especially in developed countries such as the United States, the United Kingdom, and Japan. Rheumatoid heart has been developed for nearly a decade due to improvements in socioeconomic and medical conditions. The disease has been significantly reduced. Relatively speaking, the combined valvular disease caused by degenerative changes (or mucoidosis) has a clear upward trend, which has become one of the main causes of combined valvular disease. Primary infective endocarditis has also been in recent years. It is on the rise, and it is more common to invade the left heart valve. It often invades a valve (the most common aortic valve). If it is not diagnosed in time, it will invade another valve as the disease progresses (such as the apex). In addition, some factors that cause single-valve disease can also cause secondary valvular lesions. For example, calcified aortic stenosis can cause enlargement or calcification of the left ventricle and mitral annulus, directly invading Mitral annulus and leaflet secondary mitral regurgitation, which is more common in the elderly, other causes such as systemic lupus erythematosus, secondary hyperparathyroidism, radiation injury, trauma, Werner syndrome And anorexia diet drugs can also cause mitral and aortic valve double lesions, but it is very rare in clinical practice.
(two) pathogenesis
Pathological anatomy
According to the combination of different types of lesions of the mitral valve and aortic valve (ie, stenosis or insufficiency), the mitral and aortic double lesions can be divided into the following five basic pathological types:
(1) mitral stenosis combined with aortic stenosis: this combination type is rare, the cause is almost rheumatic, and its pathological changes are basically consistent with simple mitral and aortic stenosis, pathological changes of the mitral valve The main manifestation is that the leaflets are obviously fibrotic thickening, especially the free edge and the posterior valve are severe. The leaflets may have calcification, marginal crimping, junction fusion, usually the valve area is <1.0cm2, or the diameter is <1.2cm. There are thickening, fusion, shortening, thickening of the papillary muscles, severe cases can cause subvalvular stenosis, aortic valve leaflets can also be significantly thickened, junctional fusion with calcification, regular valve area <1.0cm2, but transvalvular pressure Poor >50mmHg, left atrial enlargement, atrial fibrillation, can form a left atrial thrombus, left ventricular only pressure load increase, its size and wall hypertrophy depends on the severity of mitral and aortic stenosis, if The mitral stenosis is predominant, the left ventricle is mainly small in the heart chamber, and the wall thickness is not obvious. On the contrary, if the aortic stenosis is dominant, the left ventricle is mainly the wall-to-heart hypertrophy, and the left ventricle can be light. The degree is enlarged, but the heart is not big.
(2) mitral stenosis combined with aortic regurgitation: this type of joint is common, the cause is also mainly rheumatic, and most patients with mitral stenosis pathological changes are heavier, aortic regurgitation is relatively more Light, mitral stenosis and aortic regurgitation are more than 10%. Therefore, mitral leaflets usually have thickening, calcification, junctional fusion and other pathological changes, and the subvalvular structure is also abnormal, but Most of the aortic valve is mainly fibrotic thickening, calcification and junction fusion are not obvious, due to mitral stenosis, the left atrium can be significantly enlarged, and due to the simultaneous aortic regurgitation, the left ventricular volume load increases, left The chamber heart chamber may have a mild to moderate enlargement, the chamber wall is slightly hypertrophic or inconspicuous, and in addition, the mitral stenosis masks or reduces the severity of the aortic valve insufficiency to some extent, therefore, in this case The change of left ventricular cavity and its wall hypertrophy is not proportional to the degree of aortic insufficiency. Compared with simple aortic regurgitation of the same severity, the left ventricular cavity is enlarged. It is lighter.
(3) aortic stenosis with mitral regurgitation: this combination type is less common, the cause of which is more common with rheumatic and degenerative changes, usually aortic stenosis, mitral regurgitation is relatively more Mild, the lesion may be organic or functional, and clinically, it is most common to have secondary or mitral regurgitation on the basis of significant aortic stenosis, in which case the aortic valve Thickening, junction fusion or calcification is more obvious, left ventricular volume and pressure load are increased, therefore, left ventricular enlargement and ventricular wall hypertrophy are more obvious, but due to mitral regurgitation, left ventricular hypertrophy compared with simple aortic stenosis It is light, and the left atrium can be significantly enlarged.
(4) aortic regurgitation combined with mitral regurgitation: this type of joint is more common, can be rheumatic, degenerative, infective endocarditis, autoimmune disease or connective tissue disease (such as Ma Fang comprehensive Caused by levy, etc., in this type of joint lesions, usually aortic regurgitation is predominant, mitral regurgitation is mostly secondary, and its pathological changes are mainly related to the cause, if it is rheumatic disease, The aortic valve and mitral valve leaf are mainly fibrotic thickening, which may be accompanied by a little calcification, and the mitral annulus is obviously enlarged. The subvalvular structure and the chordae and papillary muscles are mainly thickened, if it is degenerative. Change, the valve prolapse, the annulus enlargement, may be accompanied by chordae and papillary muscles become thinner, prolonged or even broken, regardless of the cause of the aortic valve and mitral regurgitation, can lead to the left ventricle The volume load is obviously aggravated, which causes the left ventricular eccentric expansion and hypertrophy, which is more obvious than the simple aortic valve or mitral regurgitation. It is one of the most common causes of clinically large left ventricle.
(5) mitral and aortic valve mixed lesions: this combination type is the most common in clinical, the cause is almost rheumatic, is the result of repeated severe attacks of rheumatic fever, mitral and aortic valve are narrow In general, mitral valve lesions are heavier than aortic valve lesions. This type of valvular lesions is heavier, and myocardial lesions are more severe, not only the left atrium but also the left atrium. The volume and pressure load of the ventricle are increased, and the left ventricle is also significantly enlarged and/or hypertrophic.
2. Pathophysiology
Hemodynamic disturbances caused by mitral and aortic valve lesions and their effects on cardiopulmonary function are much more complicated than single valve, single lesion patients are complex and severe, different types of valvular lesions, combination and severity of atrial, ventricular The structure and function of the pulmonary circulation and coronary arteries as well as myocardial blood supply are also different.
(1) mitral stenosis combined with aortic stenosis: the effect on left atrium and pulmonary circulation is similar to that of simple mitral stenosis. Due to mitral stenosis, the left atrium is blocked in diastolic blood and the left atrial pressure is elevated. The heavier the stenosis, the more obvious the increase of left atrial pressure. With the increase of left atrial pressure, the pulmonary veins and pulmonary capillaries dilate, and the pressure also increases, leading to pulmonary congestion, edema and lung compliance, thus affecting Pulmonary ventilation function, clinical chest tightness, shortness of breath, especially fatigue, dyspnea, long-term pulmonary congestion and increased pulmonary venous pressure can further cause pulmonary artery spasm contraction, wall thickening and pulmonary vascular resistance increase, resulting Pulmonary hypertension, pulmonary hypertension can increase the right heart load, causing right ventricular compensatory enlargement and hypertrophy, which in turn affects the tricuspid valve closure function and causes right atrial enlargement. Once right heart decompensation, sputum produces right heart failure and systemic circulation. In the case of venous congestion, hepatic enlargement, ascites and lower extremity edema may occur in the clinic. In addition, continuous left atrial pressure may lead to enlargement of the left atrium and hypertrophy. On the other hand, the blood is in the enlarged left atrium. Detention, easy to form thrombus, thrombus detachment can cause arterial system embolism, on the other hand affect the left atrial muscle conduction performance, prone to left atrial myocardium cell excitation conduction velocity and refractory period are inconsistent, resulting in atrial premature contraction or Atrial fibrillation reduces the contractile function of the left atrium.
The effects on left ventricular and left ventricular function are comprehensive, mainly affected by the pressure load. The left ventricle is located between the two stenotic valves of the left heart. On the one hand, the left ventricular diastolic filling is reduced due to mitral stenosis, and the left ventricle is left. The preload is reduced, but generally mild to moderate mitral stenosis can be enhanced by strengthening left atrial contraction and left atrial pressure. The left atrial-left ventricular pressure difference is less affected, only when the severity is two. When the cusp stenosis, atrial fibrillation or heartbeat is accelerated, the effect is obvious, and the left ventricle has a tendency to shrink. On the other hand, due to the presence of aortic stenosis, the systolic left ventricular blood flow resistance increases, generally only when the aortic valve is narrowed to Approximately 1/4 of the normal area (ie <0.8cm2) will produce significant resistance, resulting in a significant increase in left ventricular afterload, central hypertrophy of the left ventricle and enlargement of the ventricular lumen, resulting in a compensatory increase in ventricular contractile force to maintain Normal cardiac output, but accompanied by decreased left ventricular compliance and increased left ventricular end-diastolic pressure, increased left ventricular diastolic pressure can reduce diastolic left atrial-left ventricular pressure difference, further affecting left ventricular filling Left ventricular compliance Can also adversely affect the left ventricular diastolic function, which in turn affects the systolic function. Therefore, in the left ventricular compensatory period, the left ventricular systolic function is compensatoryly enhanced or normal, and the diastolic function may have been abnormal, the left ventricle is normal or even Mildly enlarged, but with thicker wall thickness, the ratio of left ventricular weight to volume increases, these changes are much lighter than simple aortic stenosis, where left heart function (such as ejection fraction and short axis shortening rate) Increase or normal, if the mitral stenosis is severe, there may be a slight decrease, but this does not mean a significant decrease in left ventricular function, but may be related only to the reduction of the preload. At rest, the cardiac output is basically maintained at normal. In the scope, the effects of mitral and aortic valve stenosis on left ventricular structure and function are explained, and there is a certain offsetting effect. However, once left ventricular dysfunction, the contractile and diastolic functions can be dramatically decreased. .
Coronary artery and myocardial blood supply are mainly affected by the severity of aortic stenosis. Generally, mild to moderate aortic stenosis has little effect on coronary blood supply. Coronary blood flow and myocardial blood supply can be used when severe aortic stenosis Significant decline, the reasons are mainly related to the following factors: 1 systolic blood pressure through the stenotic aortic valve mouth to the coronary ostia, so that the systolic coronary perfusion pressure decreased; 2 ventricular concentric hypertrophy, Coronary vessels in the systolic myocardium are compressed; 3 left ventricular diastolic pressure increases, diastolic coronary perfusion resistance increases; 4 cardiac hypertrophy muscle fibers thicken, but because the number of capillaries does not increase, so the oxygen diffusion radius increases Large, myocardium is in a state of relative blood supply. In order to maintain normal cardiac output as much as possible, the left ventricle must overcome the disadvantages of insufficient preload and overload, increase myocardial contractility, and increase myocardial energy consumption and oxygen consumption. Left ventricular myocardium is in this state of oxygen supply and oxygen consumption for a long time, and it is easy to induce angina and even myocardial infarction.
(2) mitral stenosis combined with aortic regurgitation: the effect of this combination on left atrial and pulmonary circulation, as previously mentioned, is mainly related to mitral stenosis and its severity, mild to moderate The pathophysiological changes caused by stenosis of the cusp have mainly left atrial pressure, left atrial enlargement and hypertrophy, pulmonary congestion and pulmonary venous hypertension, and can produce atrial fibrillation. About 30% to 40% may be associated with left atrial thrombus. Severe mitral stenosis can further lead to pulmonary hypertension and right heart failure.
Left ventricular structural and functional changes are associated with both mitral stenosis and aortic insufficiency, mainly due to volumetric load, due to mitral stenosis, left ventricular diastolic filling, especially severe mitral valve The effect of stenosis is more obvious; however, due to the simultaneous aortic regurgitation, a part of blood flows from the aorta into the left ventricle during diastole. Therefore, the left ventricular end-diastolic volume may not decrease or even increase (this depends mainly on the aorta). According to Starling's law, the contraction force of the left ventricle increases, and the total stroke volume increases, which is beneficial to the effective stroke volume (ie, the total stroke volume minus the reverse flow) can still remain within the normal range. In this case, the left ventricle is not reduced by the mitral stenosis, but is compensated for enlargement and hypertrophy due to aortic regurgitation, but the degree is lighter than that caused by simple aortic regurgitation. Due to the better compensatory function of the left ventricle, mitral stenosis limits the rapid increase of left ventricular end-diastolic volume to some extent. Therefore, mitral stenosis combined with aortic regurgitation At the time of left ventricular compensation, the left ventricular function can be enhanced or maintained within a normal range. Although left ventricular end-diastolic volume is increased, left ventricular end-diastolic pressure can only be slightly elevated or maintained. At normal level, plus aortic valve regurgitation, aortic diastolic blood pressure and peripheral resistance are reduced, which is also conducive to maintaining left heart function, and even "false high ovulation" phenomenon, but once left ventricular decompensation occurs Left heart function can rapidly deteriorate in a short period of time, causing refractory left heart failure, and can further aggravate the influence of mitral stenosis on pulmonary circulation and right heart function. Left and right heart failure can occur in elderly patients with long course.
The blood supply to the coronary arteries and myocardium is mainly affected by the severity of aortic insufficiency. Because the coronary arteries mainly supply blood during diastole, aortic valve insufficiency is associated with coronary and myocardial blood supply compared with aortic stenosis. The greater the impact, aortic valve insufficiency can cause a significant decrease in diastolic blood pressure, thereby significantly reducing the pressure gradient between the aortic root and the myocardium, subendocardial blood vessels, so that the myocardial blood vessel perfusion is significantly reduced, to light Moderate aortic insufficiency can cause coronary artery blood supply reduction, severe aortic valve insufficiency can cause coronary artery blood supply, insufficient oxygen supply, in addition, due to increased left ventricular volume load and left ventricular hypertrophy, myocardial oxygen consumption Significant increase, therefore, even if there is no obvious coronary artery obstructive disease, it is prone to myocardial ischemia, causing angina, etc., but rarely cause myocardial infarction.
(3) aortic stenosis combined with mitral insufficiency: this combined form, the impact on the left atrium and pulmonary circulation mainly depends on mitral insufficiency and its severity, in addition, severe aortic stenosis can be aggravated two The cusp insufficiency, due to mitral regurgitation, blood regurgitation to the left atrium at the beginning of the left ventricular systole, and the entire systolic phase, plus the presence of aortic stenosis, left ventricular anterior blood flow Increased resistance, the left ventricle to the low-resistance left atrial reflux more, leading to increased left atrial pressure and left atrial enlargement, when the left ventricle is dilated, the blood can quickly flow into the left ventricle, left atrial pressure can be reduced to normal Level, therefore, the increase in left atrial pressure caused by mitral insufficiency is a dynamic change, which has a buffer gap between the left atrium and the pulmonary vein pressure, which is different from the constant left atrial pressure caused by mitral stenosis. The effect of cusp insufficiency on pulmonary circulation is also lighter than mitral stenosis. As long as the left heart function is well compensated, there is no obvious pulmonary congestion and pulmonary hypertension in a long time, clinical symptoms such as shortness of breath and dyspnea. Lighter, but once the left ventricular function is decompensated, it can further aggravate the mitral regurgitation and its effect on the left atrium and pulmonary circulation, which can significantly enlarge the left atrium and significantly increase the left atrial pressure, which is followed by obvious Pulmonary hypertension and right ventricular hypertrophy, even leading to right heart failure.
The size of the left ventricle and its function are affected by both aortic stenosis and mitral insufficiency. The pressure load and volume load are aggravated. In the diastolic phase, the left ventricle receives blood from the pulmonary circulation on the one hand, and the other In addition, due to mitral insufficiency, the systolic blood flow from the left ventricle to the blood in the left atrium, so the left ventricular end-diastolic volume load increases, which leads to the left ventricular eccentric expansion and hypertrophy. Due to aortic stenosis, left ventricular anterior blood flow resistance increases, but due to the simultaneous mitral insufficiency, blood flow easily through the mitral valve to the low pressure left atrium, so the left ventricular wall tension and Not significantly increased, or even decreased, this is significantly different from simple aortic stenosis, the left ventricle is generally dominated by volume overload, and thus mainly characterized by eccentric expansion and hypertrophy, according to Starling's law and Laplace's law, which In a combined lesion, the left ventricular systolic function can be compensatoryly enhanced. Therefore, the left ventricular ejection fraction (EF) and short axis shortening rate (FS) are increased over a relatively long period of time, and cardiac output is maintained. Often, long-lasting left ventricular volume load and/or stress overload can lead to further enlargement and hypertrophy of the left ventricle, which in turn further impairs the function of the mitral valve. Such a vicious circle can eventually lead to left ventricular dysfunction. Compensation, it is generally believed that in the presence of significant mitral insufficiency, left ventricular function may have been significantly impaired even though EF and FS are still within the normal range.
The influence on coronary artery and myocardial blood supply mainly depends on the severity of aortic stenosis and left ventricular function, generally mild to moderate aortic stenosis, as long as the left ventricle has no significant enlargement and hypertrophy, the compensation of left ventricular function is good, Coronary artery and myocardial blood supply have no significant effect. Conversely, severe aortic stenosis combined with significant left ventricular enlargement and hypertrophy can cause absolute or relative blood supply to the coronary arteries and myocardium, especially during exercise, oxygen supply and oxygen. Loss of weight, prone to myocardial ischemia and other manifestations of angina.
(4) aortic insufficiency combined with mitral insufficiency: hemodynamic disorder caused by this type of lesion, mainly to increase the volume load of the left heart system, and the effects on left atrium and left ventricle Superposition effect.
Chronic aortic insufficiency combined with mitral insufficiency is more common in degenerative and rheumatic lesions. The basic pathophysiological changes are similar to simple aortic insufficiency and simple mitral regurgitation, due to aortic insufficiency and Both mitral insufficiency progress slowly, and the cardiopulmonary has a process of adaptation and compensation. Therefore, the asymptomatic period can be very long, even if the left heart chamber, especially the left ventricle, has significantly enlarged and hypertrophy, and its clinical symptoms. Still lighter, but once the left ventricle is significantly enlarged, cardiac function is decompensated, the clinical symptoms can be rapidly aggravated, often suggesting that the left ventricular myocardium has serious pathological damage, and even irreversible pathological changes, which is associated with acute aorta and The mitral insufficiency is different. At this time, even if the valve disease is corrected, the left heart function will recover slowly or difficult to return to normal.
Prevention
Mitral and aortic valve disease 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) Mastering 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.
(4) 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, and arrhythmia are important, for aortic valve disease or prosthetic valve replacement Patients, if necessary, often use antibiotics to prevent infective endocarditis.
Complication
Mitral and aortic valve complications Complications, arrhythmia, pulmonary hypertension
Common heart failure, infective endocarditis, arrhythmia, left atrial thrombosis and thromboembolism, pulmonary hypertension, sudden cardiac death, coronary artery disease, multiple arteritis and many other complications.
Symptom
Symptoms of mitral and aortic valve symptoms Common symptoms Sudden lung infection pink foamy sputum valve thickening end sitting respiratory fatigue
The clinical manifestations of mitral and aortic valve lesions may vary significantly depending on the type of valve lesion and its severity, depending on the valve in which the lesion is relatively heavier, and sometimes the clinical condition of the lighter diseased valve. The performance will be masked or alleviated. The two valvular lesions are mainly stenosis, the symptoms appear earlier and more obvious, but the disease progresses slowly; while both valvular lesions are mainly closed, the clinical signs are obvious. Symptoms appear relatively late and mild, and the disease progresses slowly. However, in the event of heart failure, the symptoms worsen faster and the disease progresses significantly. In addition, the clinical manifestations caused by acute valvular disease are more chronic and the disease progresses rapidly. In conclusion, combined valvular lesions have earlier symptoms than single valvular lesions, the heart is generally larger, and atrial fibrillation tends to occur earlier.
Main symptoms
Symptoms caused by mitral and aortic valve lesions are mainly pulmonary circulatory congestion and hypertension, left ventricular dysfunction, and peripheral arterial insufficiency, while right heart dysfunction is less frequent and later.
(1) shortness of breath, difficulty breathing: it is the most common symptom, the incidence rate can reach 94% ~ 100%, mainly related to pulmonary vein congestion and high pressure, pulmonary interstitial edema, mostly labor dyspnea, that is, after active or physical labor Obviously, as the disease progresses gradually, severe cases may have paroxysmal nocturnal dyspnea, sitting breathing, etc., which often indicates obvious left ventricular dysfunction, usually with mitral stenosis combined with aortic stenosis. The appearance of early and obvious, and the mitral and aortic insufficiency are the main, the later and lighter, only when the left heart function is significantly reduced.
(2) palpitations: for the more common symptoms, the incidence rate is >50%, mainly related to arrhythmia and increased cardiac function, such as atrial fibrillation, frequent ventricular premature contraction or tachycardia, etc. There are obvious mitral stenosis, the latter is common in patients with aortic valve disease, and it is obvious when active or left lateral position.
(3) cough, hemoptysis: cough and pulmonary venous congestion are related to the nerve reflex caused by bronchial bronchus, mostly dry cough, usually at night or after labor, if there is a cough with pulmonary infection, hemoptysis is mainly due to bronchial submucosal vein or internal Membrane microvascular and other rupture, light in the sputum with blood, severe hemoptysis can occur, the amount of bleeding can reach hundreds of milliliters, but generally can stop on their own, rarely hemorrhagic shock, in addition, acute pulmonary edema can occur There is a pink foamy sputum, which is common in the presence of a significant mitral stenosis.
(4) fatigue, fatigue and hyperhidrosis: common in mitral insufficiency combined with aortic valve disease, the incidence rate is about 80%, more common after activities, it is generally believed that fatigue, fatigue and cardiac output Reducing the relative blood supply to the limbs is related to fatigue, fatigue and fatigue caused by bacterial endocarditis, but also related to progressive anemia, and hyperhidrosis, especially above the body, may be related to autonomic dysfunction.
(5) angina pectoris: coronary artery insufficiency, myocardial oxygen supply and oxygen consumption imbalance, mainly seen in patients with severe aortic stenosis or insufficiency, the incidence of the former is about 20% to 60%, the latter nearly 50% More than fatigue, induced after emotional excitement, but can also occur at rest, its nature is similar to angina caused by coronary heart disease, but the coronary artery itself can be no obvious lesions.
(6) Dizziness and syncope: mainly seen in patients with aortic stenosis, the incidence rate is about 30%, often after labor or sudden changes in body position (such as sudden body anteversion or standing from the squat position), light There is only a sense of dizziness, and severe cases can cause syncope, which can last from several minutes to tens of minutes. The mechanism of its occurrence is not clear. It is generally believed that it may be associated with peripheral vasodilatation or paroxysmal severe arrhythmia, resulting in insufficient blood supply to the cerebral circulation. Related, it may also be related to carotid sinus allergy.
(7) sudden death: This is one of the most serious symptoms, more common in severe aortic stenosis and/or insufficiency, the incidence is about 20% to 25%, the latter is about 10%, the reason may be Associated with sudden fatal arrhythmias (such as ventricular fibrillation, ventricular tachycardia, etc.), most patients may have a history of repeated angina or syncope before sudden death, but it can also be used as a first symptom.
(8) embolization: more common in systemic embolism, mainly seen in patients with rheumatic mitral valve disease and left atrial thrombus, as well as patients with infective endocarditis with valvular hernia, left atrial thrombus mainly caused by cerebral embolism, limb hemiplegia The incidence rate is about 16% to 19%. The bacterial sputum can be detached from a single site or multiple sites. The incidence rate is about 15% to 30%. The most common cerebral embolism can cause hemiplegia, meningitis or brain abscess. , followed by important internal organs (such as lungs, kidneys) and extremity arteries, as well as fundus, finger (toe), small arteries or capillaries in the skin and mucous membranes, resulting in abnormal organ dysfunction, limb pain or Movement disorders, abnormal vision and other performance.
(9) Others: Whether it is mitral valve disease or aortic valve disease, when the lesion develops to the middle and late stage, it can affect the function of the tricuspid valve and the right heart, resulting in right heart dysfunction and Symptoms of tricuspid valve disease, mainly the systemic venous system (especially the digestive tract), such as loss of appetite, bloating, jaundice, lower extremity edema.
2. Main signs
The signs of typical mitral and aortic valve lesions are basically a combination of signs of simple mitral and aortic valve disease, but often characterized by signs of a heavier valve, sometimes masking or Alleviate the signs of another lighter diseased valve.
(1) Lifting pulsation: due to enlarged heart chamber, hypertrophy of the ventricle, and strong heartbeat, more common in patients with obvious mitral regurgitation combined with aortic valve disease, especially in patients with left ventricular hypertrophy, elevated urge With the apex of the apex, it can also be diffused to the entire precordial area. Men are more women than women, and those who are thinner are more obese than those who are obese.
(2) expansion of the heart: except for patients with severe mitral stenosis, left ventricular enlargement is not obvious, mitral and aortic valve lesions mostly have a certain degree of left ventricular enlargement and hypertrophy, percussion can be found The voiced sounds expand to the left, especially in the aortic valve insufficiency combined with mitral insufficiency.
(3) Heart murmur, heart sound and heart rate changes:
1 systolic murmur and heart sound changes: mainly caused by aortic stenosis and mitral insufficiency, typical aortic stenosis murmur is high-profile, loud, jet murmur, rough, loudness often 3 to 4 Above the level, the second intercostal space of the right sternal border and the left sternal border of the third and fourth ribs are most obvious, more with systolic tremor, and conduction to the neck, a few can also be transmitted along the left sternal border or apex, the main The more severe the stenosis, the longer the duration of the murmur, and sometimes the S2 abnormal division, but at the same time the obvious mitral stenosis, the murmur of the aortic stenosis can be light and the duration is reduced due to the decrease of cardiac output. Shortened, A2 is often weakened due to thickening of the valve and severe calcification.
The typical mitral regurgitation is often a full-systolic murmur. The loudness is often above 3 or 3, located at the apex of the apex, and is transmitted to the left and left scapula. S1 is often masked or weakened by noise. P2 is often hyperthyroidism. When combined with obvious aortic stenosis, the noise can be enhanced. At the same time, there is obvious aortic valve insufficiency. Because of left ventricular hypertrophy, the apex is turned clockwise to the left and the apical mitral insufficiency. The noise is weakened.
2 diastolic murmur and heart sound changes: mainly caused by mitral stenosis and aortic valve insufficiency, typical mitral stenosis murmur is apical diastolic, late low-profile rumbling-like murmur, noise transmission is more limited, mostly 2 ~ Level 3, although its loudness has a certain relationship with the severity of mitral stenosis, but the two are not necessarily proportional, S1 is often hyperthyroidism, if the valve activity is still good, it can produce an open sound, P2 hyperthyroidism, but when there is obvious main In the case of a stenosis of the aortic valve, the murmur of the aortic stenosis can mask the murmur intensity of the mitral stenosis.
The typical aortic insufficiency murmur is the diastolic water-like diminished murmur in the early and middle diastolic, which is most clearly between the 2 and 3 ribs on the left sternal border. The loudness is generally above 2 to 3, and if there is obvious mitral stenosis at the same time. It can weaken the intensity of the noise, and the range of noise transmission is wide. It often conducts down the left edge of the sternum, reaching the apex of the apex and the left anterior line. Sometimes the whole anterior region can be heard, the heart sound S1 is often weakened, and the aortic valve is insufficiency. In severe cases, A2 is also weakened or absent.
3 heart rhythm changes: there may be abnormal arrhythmia in the presence of atrial fibrillation, with different heart sounds, mainly seen in rheumatic mitral valve disease combined with obvious left atrial enlargement, in addition, left ventricular significant hypertrophy and enlargement, may be accompanied There is ventricular arrhythmia, which is common in multiple ventricular premature contractions.
(4) Peripheral vascular signs: mainly seen in patients with obvious aortic regurgitation, such as water impulses, increased pulse pressure difference, femoral artery gunshots and capillary pulsation signs.
Examine
Examination of mitral and aortic valve disorders
Color echocardiography
Echocardiography includes M-mode ultrasound, two-dimensional ultrasound, Doppler ultrasound, and transesophageal ultrasound. In recent years, three-dimensional or four-dimensional imaging has been performed on the basis of two-dimensional ultrasound images, so that echocardiography is used to diagnose the morphology of valvular disease. Functional changes are more precise.
M-mode ultrasound can observe the activity state of each valve leaflet, measure the inner diameter or thickness of each heart chamber, wall and large blood vessel, so that the type of each valve lesion can be qualitatively analyzed, and the size of each heart chamber, large blood vessel size and cardiac function can be quantitatively analyzed. Variety.
Two-dimensional ultrasound can obtain the cut surface of many different acupoints of heart and large blood vessels, dynamically understand the activity of each valve, the severity of the lesion, the inner diameter of each heart chamber and the thickness of the atrioventricular wall, combined with Doppler ultrasound and color Doppler flow. Imaging, to further understand the characteristics of blood flow spectrum of each valve, heart chamber and large blood vessels, direction, velocity, nature, source and phase of blood flow, quantitative analysis of the severity of stenosis or regurgitation, macrovascular vessels Pressure and transvalvular pressure difference.
Transesophageal echocardiography can obtain the cut surface that can not be obtained by surface ultrasound, and can greatly reduce the mutual interference between the two valve lesions, and can make sensitive and accurate judgments on mitral and aortic valve lesions. Especially for the immediate evaluation of the intraoperative mitral or aortic valve formation effect is of great value.
The echocardiographic features of the mitral and aortic valve lesions are basically consistent with the characteristics of the corresponding simple mitral or aortic valve lesions, but the following points are worth noting:
(1) When combined with significant aortic valve disease: Left ventricular compliance decreased significantly due to left ventricular hypertrophy or enlargement. At this time, the continuous half-pressure time (HPT) method was used to determine the continuous Doppler spectrum. The area of the mitral stenosis is not accurate, and it is often estimated to be too high, but should be determined by the area method.
(2) When mitral stenosis combined with aortic stenosis: due to the relative reduction of cardiac output, it is not reliable to evaluate the severity of the aortic valve stenosis by Doppler measurement of transvalvular pressure difference. low.
(3) When both the mitral valve and the aortic valve are closed, the left ventricular enlargement and hypertrophy are significant. The measurement of the left ventricular volume by the Cube method and the Teichholy method is not accurate, and the Simpsorrs multiplanar method should be adopted.
2. X-ray inspection
(1) Chest radiograph examination: ordinary X-ray plain film examination mainly observes the morphological changes of each compartment and large blood vessels and the changes of lung texture through different body positions, and indirectly studies and analyzes heart valves based on hemodynamic changes. Lesion.
When the mitral and aortic valve lesions are mild, the changes of X-ray plain film may not be obvious; when the valvular lesion is heavier, there may be different degrees of X-ray signs of room, ventricular enlargement and pulmonary hypertension, such as left atrium. Expanding the double-spot shadow on the anterior slice, the left anterior oblique position can be seen in the left main bronchus elevation, and the bronchial angle is increased (over 45°); the left ventricular enlargement is visible on the left lower heart edge to the lower left, and the left anterior oblique position is visible behind the heart. The gap disappeared, and the posterior and posterior border of the left ventricle protruded backward and downward to overlap with the spine; the Kerley line may appear in the pulmonary hypertension with pulmonary hypertension. The pulmonary vascular texture may have thicker inner side shadows, and the outer band is sparse and small (Fig. 5). It is said that the X-ray plain film of the mitral and aortic valve lesions is mainly caused by the heavier lesions in the two valves. The aortic valve insufficiency is the main one, the left ventricle is enlarged, and the pulmonary circulation is higher. Light or inconspicuous, especially the aortic valve and mitral valve are closed, the left ventricular enlargement is the most obvious; conversely, mitral stenosis and aortic stenosis, the left atrial enlargement and pulmonary circulation hypertension are obvious. Left ventricular enlargement It is not obvious.
(2) Cardiac catheterization and cardiovascular angiography: both the mitral valve and the aortic valve are left heart valves. Therefore, left heart catheterization and angiography are generally performed. Left atrial catheterization can measure left atrial, ventricular and aortic pressure. , mitral and aortic valve transvalvular pressure difference, qualitative understanding of mitral and aortic valve lesion types, left ventricular or retrograde aortic angiography can quantitatively study aortic stenosis or regurgitation and mitral insufficiency The severity, but in the presence of significant mitral stenosis, cardiac catheterization and angiography often underestimate the severity of aortic stenosis or insufficiency due to a relative decrease in cardiac output.
3. ECG
Almost all mitral and aortic valve lesions have abnormal ECG manifestations. The severity depends mainly on the degree of atrial, ventricular enlargement or hypertrophy, but lacks specificity. Most patients have left atrial enlargement and left ventricular hypertrophy. Or with the performance of strain, such as room-type P wave, V1 lead S wave depth, V5 lead R wave high tip, ST segment decline and T wave inversion, if double or left ventricular hypertrophy is obvious, right bundle branch block may occur Even left (front) bundle branch block, if the disease is due to rheumatism, most of the left atrial enlargement is accompanied by atrial fibrillation, and if endocarditis or degenerative changes, most cases of left atrial enlargement without atrial fibrillation Trembling.
Diagnosis
Diagnosis and diagnosis of mitral and aortic valve diseases
The diagnosis of mitral and aortic valve combined valve not only requires qualitative characterization of the nature of valvular lesions, but also requires quantitative determination of the severity of each valvular lesion and the state of cardiac function. In general, according to medical history, clinical manifestations, the focus is on murmur Nature, combined with chest X-ray and electrocardiogram and other auxiliary examinations, can be initially qualitative diagnosis, combined with cardiac color Doppler ultrasound examination, more can be more positive qualitative (including etiology) and quantitative diagnosis, but sometimes quantitative diagnosis is more difficult, need to be combined with cardiac catheterization Or comprehensive analysis and judgment of angiographic data, sometimes in-situ direct exploration to obtain a final and clear diagnosis.
In the diagnosis and differential diagnosis of mitral valve combined with aortic valve disease, special consideration should be given to the following points:
1. Identification of the source and nature of heart murmur
Heart murmur is the most characteristic change of heart valve disease. It can often judge the lesion and pathological type of the heart according to the location and nature of the heart murmur, but sometimes it is atypical and different due to the location, conduction direction and nature of the noise. The overlap or interference of the murmur between the diseased valves often causes difficulties in judgment. The heart murmurs that are often required to be identified in clinical practice are as follows:
(1) apical systolic murmur: apical systolic murmur is mostly caused by mitral insufficiency, but a few obvious aortic stenosis systolic murmur can also be louder at the apex of the heart, but the latter's murmur Generally rough, jetting, in tachycardia, left heart failure, the murmur becomes shorter and softer, if necessary, can be used for drug test identification, when the intravenous drip booster, due to increased left ventricular ejection resistance, the aorta The murmur of the stenosis is weakened, and the murmur of the mitral insufficiency is enhanced. On the contrary, when inhaling isopropyl nitrite, the left ventricular ejection resistance is decreased due to peripheral vasodilation, and the aortic stenosis is enhanced. Incomplete occlusion of the valve is relieved.
(2) apical diastolic murmur: in addition to organic mitral stenosis can produce typical apical diastolic murmur, obvious aortic insufficiency can also produce relative mitral stenosis murmur in the apex (Austin -Flint murmur), the former is pathological, the murmur is more rumbling, with S1 enhancement; while the latter is functional, the murmur is mostly low-key, soft and airy, accompanied by watery murmur in the second auscultation area of the aortic valve And the drug test results are the same as the aortic regurgitation murmur, but the murmur results of the mitral stenosis are opposite, but it is worth noting that the obvious aortic insufficiency murmur can mask the murmur of mild mitral stenosis, thus Caused the latter's missed diagnosis.
(3) diastolic murmur at the bottom of the heart: the murmur of the aortic insufficiency and the Graham-Steel murmur are often identified in this part. The latter is caused by pulmonary hypertension, causing relative pulmonary insufficiency, and the noise is usually light. It is enhanced when deep inhalation, and P2 is significantly hyperactive; the former murmur is louder at the end of expiration, more common in clinical, sometimes combined with echocardiography and X-ray examination to identify easily.
2. Determination of the nature and severity of valvular lesions
Although mitral and aortic valve lesions account for the majority of valvular disease, in valvular lesions, one of the valvular lesions is often predominant, and sometimes a valvular lesion masks or reduces the performance of another valvular lesion or Severity, clinically misdiagnosed or missed as a single valve disease, or difficult to identify the nature of the relatively small valve disease (ie functional or organic), therefore, in the diagnosis and differential diagnosis of combined valvular disease, Special attention should be paid to the nature of the milder valvular lesions and the severity of the following types of lesions. This is an important reference for the surgical treatment of valvular disease, especially for the selection of appropriate surgical timing and surgical procedures.
(1) mitral valve disease with mild aortic stenosis: almost all rheumatic heart disease, in one case is mitral stenosis with mild aortic stenosis due to mitral valve Significant stenosis, resulting in a relatively reduced cardiac output, can mask or reduce the severity and clinical manifestations of mild aortic stenosis; another case is mitral insufficiency combined with mild aortic stenosis, due to The cusp regurgitation significantly obscures or reduces the increase in left ventricular ejection resistance caused by aortic stenosis, thereby reducing the clinical manifestations caused by aortic stenosis. Therefore, in the case of mitral valve disease, if If there is a history of angina or syncope, or an auxiliary examination showing obvious signs of left ventricular hypertrophy and atrial ablation of the aortic valve, the possibility of aortic stenosis should be highly vigilant.
(2) mitral valve disease combined with mild aortic valve insufficiency: mitral stenosis and mild aortic insufficiency are more common, the cause is mostly rheumatic, due to mitral stenosis, Causes left ventricular diastolic filling blood volume reduction and cardiac output reduction, can reduce the reflux of aortic valve insufficiency and its clinical manifestations, such as pulse pressure difference, the diastolic murmur of the aortic valve second auscultation area becomes light Etc., and the latter is also interfered by the rougher diastolic murmur caused by mitral stenosis of the apex, which is easily neglected. The aortic valve causes left ventricular enlargement and is not obvious due to mitral stenosis, so that the chest X-ray is flat. The diagnostic value of films, electrocardiograms, etc. is not significant. In this case, careful cardiac ultrasonography, especially transesophageal ultrasonography, may be helpful in the diagnosis of mild aortic insufficiency.
(3) aortic valve disease combined with mild mitral insufficiency: there are two cases, one is mainly aortic stenosis with mild mitral insufficiency, more common in elderly calcified aortic valve In patients with lesions, mitral insufficiency is mostly secondary and relative. Aortic valve stenosis increases left ventricular blood flow resistance, which has an enhanced effect on mitral regurgitation, but the murmur is generally softer. Diagnosis is not difficult, the other is mainly aortic insufficiency combined with mild mitral regurgitation, more common in clinical, more common in degenerative or infective endocarditis, and Ma Fang syndrome Patients, unless infective endocarditis directly invades the mitral valve leaflet, in most cases mitral insufficiency is secondary and relative, mainly due to obvious closure of the aortic valve leading to left ventricle and two
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