Concomitant disorders of the mitral, aortic, and tricuspid valves
Introduction
Introduction to the combined disease of mitral, aortic and tricuspid valves The mitral valve, aortic valve and tricuspid valve are often referred to as triplevalvedisease. It is also a common type of combined valvular lesion. Tricuspid valve disease is mostly in the mitral and aortic valve. On the basis of the lesion, functional closure due to pulmonary hypertension and right ventricular enlargement. basic knowledge The proportion of the disease: the probability of the population is 0.6% Susceptible people: no special people Mode of infection: non-infectious Complications: Infective endocarditis Arrhythmias Pulmonary hypertension
Cause
Causes of combined disease of mitral, aortic and tricuspid valves
(1) Causes of the disease
The etiology of trivalvular lesions is most common with rheumaticity, followed by degenerative changes and infective endocarditis. If the three valves are organic lesions, they are almost rheumatic.
(two) pathogenesis
Pathological change
For the three-valve lesion, there is no clear classification method. Generally, based on the mitral and aortic valve disease, according to the nature of the tricuspid lesion, it is divided into the following two basic pathological types:
(1) mitral and aortic valve double valve disease combined with tricuspid functional atresia: this type is the most common, accounting for more than 95%, the cause is mainly rheumatic, tricuspid lesions are almost always secondary After mitral and aortic valve disease, it is mainly related to the expansion of the tricuspid annulus caused by pulmonary hypertension and right ventricular enlargement, and pulmonary hypertension and right ventricular enlargement are mainly secondary to left heart valve disease, especially severe two. According to the anatomical features of the tricuspid annulus, the annulus of the septal annulus is very small. Therefore, the expansion of the tricuspid annulus caused by the enlargement of the right ventricle is mainly dominated by the anterior and posterior annulus, resulting in three The anterior and posterior lobes of the cusp are in poor union with the valvular leaflets, resulting in functional atresia, and the texture and activity of the tricuspid leaf itself are not abnormal.
(2) mitral and aortic double lesions combined with tricuspid organic disease: this type is quite rare, the cause is almost rheumatic, and occasionally mitral and aortic valve lesions are rheumatic, and Tricuspid valve disease is infective endocarditis, the type and characteristics of pathological changes of mitral and aortic valves in rheumatic trivalvular lesions (see section on mitral and aortic valve disorders), rheumatic three Most of the cuspidal lesions coexist with stenosis and insufficiency. The extent and extent of the lesions are lighter than those of the mitral valve lesions. The more common manifestations are fibrosis thickening of the valve leaflets, free marginal crimping, but rare calcification; The boundary between the septum and the anterior flap is obvious. Sometimes there is a slight fusion between the posterior and anterior flaps. There is less fusion and shortening of the chordae under the flap, and the annulus has different degrees of expansion.
2. Pathophysiology
Three-valve lesions can not only cause obvious left-heart system hemodynamic disturbance, but also cause hemodynamic changes in the right heart system. Therefore, it has obvious effects on the functions of heart, lung, liver and kidney and other important organs. The mitral and aortic valve disease is more complicated, and the degree of influence depends mainly on the type and severity of each valvular lesion.
The mitral and aortic valve lesions in the three-valve lesion mainly cause hemodynamic disturbance of the left heart system and changes in the volume and/or pressure load of the left heart chamber, thereby further affecting cardiopulmonary function (see mitral valve for details). And aortic valve disease), tricuspid valve disease mainly causes hemodynamic disturbance of the right heart system, mainly manifested as systemic venous system of congestion and liver and kidney, gastrointestinal function changes.
When the tricuspid stenosis occurs, the right atrial blood enters the right ventricle during diastole, causing blood to accumulate in the right atrium, resulting in increased right atrial pressure and enlarged heart chamber. Compared with the left heart system, the right heart belongs to the low pressure system. Lower, the area of the tricuspid valve is 6 ~ 8cm2, the pressure difference between the right atrium and the right ventricle in the diastolic period is very small, and is susceptible to breathing. When the tricuspid stenosis to the area of the valve is below 2cm2, the right atrium and the right When the average diastolic pressure difference between the chambers is >4~5mmHg, systemic venous congestion can be caused. Therefore, on the one hand, the tricuspid stenosis reduces the right ventricular diastolic filling, which in turn causes the pulmonary circulation to decrease and the left heart discharge to decrease. On the one hand, the circulation of venous blood caused by the circulation of the right ventricle increased the resistance of the right atrium, the amount of blood returned to the heart, venous congestion in the systemic circulation, resulting in clinical signs of jugular venous engorgement, hepatomegaly, lower extremity edema and other signs of right ventricular dysfunction or failure, but due to Tricuspid stenosis reduces the amount of blood from the right heart to the pulmonary circulation, and to some extent reduces the impact of mitral stenosis on the pulmonary circulation.
Tricuspid atresia, whether it is functional or organic lesions, due to partial blood flow from the right ventricle to the right atrium during systole, resulting in increased pressure and increased cardiac chamber and tricuspid stenosis due to excessive volume overload in the right atrium The same can cause blood circulation disorder and congestion of the systemic venous system. Because the tricuspid regurgitation is often accompanied by pulmonary hypertension, the right ventricular compensatory function is poor, and therefore, it can eventually lead to right heart failure.
Because the onset of tricuspid valve disease is often concealed, and often secondary to left heart valve disease, the disease progresses slowly. Therefore, the pathophysiological changes of the right heart system caused by early lesions are mild, easily overlooked or left heart valve. Pathophysiological changes caused by lesions are concealed. Only when the tricuspid valve lesions are obvious, obvious hemodynamic changes in the right heart system will occur. At this time, it is often suggested that the disease has entered the middle and late stages. In addition, the left heart valve and Left heart function also has a significant effect on the tricuspid valve and right heart function. When left ventricular dysfunction, tricuspid atresia and right ventricular dysfunction can be aggravated.
Prevention
Prevention of combined disease of mitral, aortic and tricuspid valves
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.
Complication
Complications of mitral, aortic, and tricuspid complication Complications Infective endocarditis 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, aortic, and tricuspid complication common symptoms jugular venous fatigue fatigue loss of appetite, valve thickening, shortness of air supply, coronary artery insufficiency
The clinical manifestations of trivalvular lesions are a combination of clinical manifestations of various diseased valves. Mitral and aortic valve lesions mainly produce symptoms and signs of left ventricular dysfunction and arterial insufficiency, while tricuspid valve disease mainly produces The symptoms and signs of right heart dysfunction and systemic venous system congestion are mainly determined by the severity of each diseased valve and its combination. In general, the symptoms and signs of mitral and aortic valve disease It appears earlier and more obvious, and the symptoms and signs of tricuspid valve disease appear relatively late and lighter. The early stage is easily concealed by the symptoms or signs of the left heart valve. Once the clinical manifestations of obvious right heart dysfunction appear, it is often prompted. Left and right heart function have obvious damage. It is worth noting that when there is obvious tricuspid stenosis or right heart failure, the respiratory symptoms and signs caused by mitral stenosis can be alleviated.
Main symptoms
(1) Left ventricular dysfunction: mainly caused by mitral and aortic valve disease, mainly palpitations, shortness of breath, cough, hemoptysis, fatigue, fatigue and so on.
(2) Insufficient arterial blood supply: If there is obvious aortic stenosis or regurgitation, it can cause insufficient blood supply to the coronary arteries, causing angina pectoris. If the cerebral arterial blood supply is insufficient, it may cause dizziness or fainting.
(3) the performance of right heart dysfunction: mainly manifested as systemic venous system congestion symptoms, when the liver, gastrointestinal congestion, body water and sodium retention, there may be pain or bloating in the liver area, loss of appetite, nausea, belching and lower limbs Edema, etc.; if accompanied by cardiogenic cirrhosis, jaundice, bleeding gums and nosebleeds may occur.
2. Signs
The signs of trivalvular lesions are basically a combination of left valvular lesions and signs of tricuspid lesions, mainly vascular engorgement and pulsation, cardiac enlargement and lift impulses, changes in heart murmurs and heart rhythms, and tissue congestion and Edema and other performance.
(1) Lifting impulsiveness: mainly related to left and right ventricular hypertrophy, enlargement and strong heartbeat. Because of the obvious tricuspid atresia in this type of patient, ventricular hypertrophy is often biventricular, which is related to mitral valve. The left atrial hypertrophy is different from the aortic valve double lesions. The ascending impulse is mainly in the anterior region. In some adolescent patients with significant double-chamber hypertrophy, the left chest wall bulge may appear, which is significantly higher than the right chest wall.
(2) enlargement of the heart: the left and right heart chambers of the three-valve lesions can be significantly enlarged. Therefore, the percussion can be found to expand to the bilateral sides of the heart, and the three-valve lesions are mainly closed by the insufficiency. most obvious.
(3) Heart murmur, heart sound and heart rhythm changes: typical three-valve lesions can be heard in the auscultation area of each valve and the corresponding systolic and diastolic murmurs, because the mitral and aortic valve lesions are mostly mixed lesions, and Tricuspid valve lesions are mostly insufficiency. Therefore, the mitral and aortic valve auscultation areas are mostly double-phase murmurs. In the tricuspid auscultation area (4th, 5th intercostal space or xiphoid in the left sternal border), mainly contraction Period murmur, diastolic murmur is rare, because the tricuspid valve transvalvular pressure difference is small, so the murmur is relatively light, when the tricuspid valve lesion is light, the murmur is easily concealed by the noise of the left heart valve lesion, in addition, the heart sound S1 and A2 Often due to poor valve thickening activity is weakened or masked by noise, P2 often hyperthyroidism, mainly related to the combination of different degrees of pulmonary hypertension.
Rheumatic tri-valve disease is often accompanied by atrial fibrillation. Therefore, auscultation can be found that the heart rhythm is absolutely uneven and the heart sounds are different.
(4) jugular vein engorgement, pulsation: This is one of the characteristic signs of obvious tricuspid regurgitation, the right ventricular blood refractory to the right atrium during systole, the pulsation is transmitted to the jugular vein, typical with each The second systole shows that the head is slightly moving to the left.
(5) Liver enlargement, dilated pulsation is caused by increased hepatic blood volume caused by tricuspid regurgitation, and the result of congestion and expansion mainly occurs in the middle and late stage of contraction, and most of them are diffuse pulsation of the whole liver. In addition, hepatic jugular venous return Positive signs, these are also the main signs of tricuspid regurgitation.
(6) Ascites, lower extremity edema: This is the manifestation of tricuspid valve disease and right heart failure, mainly caused by congestion of the systemic venous system.
Examine
Examination of combined mitral, aortic and tricuspid valves
The auxiliary examination of the three-valve lesions mainly includes color echocardiography, electrocardiogram, X-ray examination, cardiac catheterization and cardiovascular angiography, etc., which are commonly used in the past three clinically.
Color echocardiography
The echocardiographic features of the three-valve lesions are basically consistent with the corresponding single-valve lesions, but it should be added that due to the anatomical location, it is often difficult and inaccurate to determine the tricuspid valve orifice area and annulus size by ultrasound. When the tricuspid valve is an obvious organic lesion (such as stenosis with insufficiency), it is also not reliable to estimate the pulmonary artery pressure by measuring the tricuspid regurgitation characteristics. In this case, direct measurement by cardiac catheterization is used. It is appropriate.
2. ECG
Mainly characterized by double-chamber, double-chamber hypertrophy, such as double-room hypertrophy, P wave is tall or wide and has a notch, but there is no change in atrial fibrillation; when double-chamber hypertrophy, V1 lead S wave Wide, V5 lead R wave high tip.
3. X-ray inspection
Mainly manifested as heart shadow enlargement and pulmonary vascular changes.
The enlargement of the heart shadow is mainly caused by the enlargement of the heart and shadow of the corresponding room and the corresponding part of the room. For example, the enlargement of the right atrium caused by the tricuspid valve disease mainly enlarges the heart shadow to the right side, and the enlargement of the left atrium caused by the mitral valve disease. Can be left posterior, left upper, right or bilateral enlargement, right ventricular enlargement caused by pulmonary hypertension or tricuspid valve disease mainly enlarges to the left side, and left ventricular enlargement caused by mitral or aortic valve disease mainly The lower left is enlarged. Therefore, the "four-bow" phenomenon of the left edge of the heart and shadow, and the typical signs of the double-shadow shadow may appear on the chest radiograph, but more common is the pattern of enlarged heart shadows with different shapes and forms. "Giant heart (cardiac-thorax ratio > 0.80)", which is mainly related to the degree and orientation of each heart cavity expansion caused by different types of valvular lesions.
Pulmonary vascular changes are mainly manifestations of pulmonary hypertension, often pulmonary arteries, pulmonary veins, pulmonary capillaries, multiple high pressure coexist, pulmonary hypertension is mainly characterized by pulmonary artery segmentation, hilar enlargement, lung field with thinning, twisted, outside With lung pattern sparse, small, pulmonary vein hypertension is mainly characterized by enlarged hilar shadow, but the edge is fuzzy, the pulmonary vein is thickened, generally the upper leaf vein is enlarged, while the lower leaf vein is thinner, and the pulmonary capillary hypertension is pulmonary. The brightness is reduced, there is a mesh shadow, and the Kerley line appears.
4. Cardiac catheter and angiography
Right heart catheterization has a major role in the presence or absence of tricuspid stenosis and pulmonary artery pressure. The average diastolic pressure gradient of the tricuspid valve is 2 mmHg, indicating the presence of tricuspid stenosis. Retrograde aortic angiography can confirm aortic valve disease. The type and severity of coronary angiography can determine the presence or absence of coronary heart disease and its severity.
Diagnosis
Diagnosis and diagnosis of combined mitral, aortic and tricuspid valves
Diagnostic criteria
Diagnosis can be made based on clinical symptoms and related examinations. Auxiliary examinations mainly include color echocardiography, electrocardiogram, X-ray examination, cardiac catheterization and cardiovascular angiography.
According to the medical history, main symptoms and signs, combined with color echocardiography, electrocardiogram and X-ray, the diagnosis of tricuspid valve disease is not difficult. It is worth noting that tricuspid valve disease is sometimes mild or clinical manifestation is not typical. It is easy to miss the diagnosis or underestimate the severity of the lesion. Sometimes the symptoms and signs of venous congestion in the patient are difficult to judge clinically mainly due to tricuspid valve disease or right ventricular dysfunction caused by left heart valve disease. When there is a clear presence of mitral and aortic valve lesions, the following conditions should be considered: tricuspid valve disease may be considered:
1. The 4th, 5th intercostal space of the left sternal border and the lower part of the xiphoid can be audible and systolic murmur, enhanced during inhalation, and the most clear under the xiphoid.
2. The mitral stenosis is severe, but the pulmonary symptoms and signs are mild, which is not commensurate with the severity of mitral stenosis.
3. The left heart function is normal, but the symptoms and/or signs of right heart dysfunction are obvious.
Echocardiography plays a decisive role in the diagnosis of tricuspid valve disease and its nature. Cardiac catheterization is of great value in the diagnosis of tricuspid stenosis and the identification of tricuspid regurgitation. Tricuspid stenosis during tricuspid stenosis When the tricuspid regurgitation is >60mmHg, it is generally expressed as functional. If the right ventricular systolic pressure is <40mmHg, it may be organic.
