Stenosis of the mitral valve( mitral stenosis) - Causes, symptoms and treatment. MF.

Causes of stenosis
Symptoms of stenosis of the mitral valve
Diagnosis
Treatment of mitral stenosis
Lifestyle
Complications of
Forecast

Mitral valve defects take the leading place among all acquired heart defects, most often a combination of stenosis and insufficiency( incomplete closure of the valves), and isolated mitral stenosis is observed in about 30% of the defects of this valve.

The mitral valve is a connective tissue formation located on the border of the left atrium and left ventricle. It consists of two thin and movable valves( anterior and posterior), the main function of which is as follows: when the blood flows from the atrium into the ventricle, the leaflets diverge, flowing through the blood stream, and when the blood flows from the ventricle into the aorta, the valves close,the return of blood to the atrium. Ideally, valve flaps should completely close, overlapping the left atrioventricular orifice( between the atrium and the ventricle).The area of ​​the latter in adults is approximately 4 - 6 square centimeters.

If replacement of the normal connective tissue of the valve occurs on the scar, then adhesions and fusion between the valves or in the fibrous ring surrounding the valve develop. This pathological condition is called stenosis of the mitral valve( synonym - stenosis of the left atrioventricular orifice).

Mitral valve stenosis is a disease related to a group of acquired heart defects and is characterized by the following features:

- occurs due to organic damage of the connective tissue of valve flaps, for example, inflammation in the heart for rheumatism, bacterial endocarditis;
- as a result of cicatricial changes a narrowing of the aperture between the atrium and the ventricle is formed, creating an obstacle to the movement of blood from the atrium to the ventricle;
- this obstruction leads to an increase in pressure in the left atrium with its hypertrophy( thickening of the walls) and a decrease in the release of blood into the left ventricle and, consequently, into the aorta;that is, violations of hemodynamics develop( blood flow in the heart and in the entire body);
- without surgical treatment, the wear of the heart muscle and its inability to circulate blood through the body, which leads to a violation of blood supply and nutrition of all tissues of the body.

The causes of stenosis of the mitral valve

In most cases, the cause of mitral stenosis, as well as of other acquired heart diseases, is rheumatism( acute rheumatic fever) with the development of rheumatic heart disease - inflammation of the muscular and connective tissues of the heart.

Symptoms of mitral stenosis

The severity of clinical signs of stenosis varies depending on the stage of the process( in Russia the classification according to AN Bakulev is widespread).

In the stage of compensation for , clinical symptoms are not observed due to the fact that the heart and the body adapt to the existing anatomical disorders by means of compensatory mechanisms. This stage can last many years, especially if the narrowing of the valve ring is not very large - about 3 cm2 or more.

In the stage of the subcompensation, as the atrioventricular orifice is progressively narrowed, the adaptive mechanisms fail to cope with the increased burden on the heart. There are the first symptoms - shortness of breath with physical exertion, pain in the heart and in the interblade area on the left with or without exercise, a feeling of disruption in the heart and heart palpitations, purple or blue coloration of the skin of the fingertips, ears, cheeks( cyanosis), chilliness,coldness of the extremities. Atrial fibrillation may also occur.

In , the stage of decompensation of is marked depletion of the heart muscle, blood stasis is formed first in the lungs, and then in all organs and tissues of the body. Dyspnea takes on a permanent character, the patient can breathe only in the position of a semiside( orthopnea), often there is a life threatening condition - pulmonary edema.

Later in the stage of severe decompensation, cough, hemoptysis, edema of the shins and feet, abdominal enlargement due to intracavitary edema, pain in the right upper quadrant due to blood filling of the liver( can develop cardiac cirrhosis of the liver).This stage can still be reversible in the conduct of drug therapy.

Further in the terminal stage of ( the stage of irreversible changes in the heart muscle and the body) arterial pressure decreases, there is swelling of the whole body( anasarka).In connection with the violation of metabolic processes in the heart and in all internal organs, there is a fatal outcome.

Diagnosis of mitral valve stenosis

The diagnosis of mitral stenosis is established based on the following data.

1. Clinical examination. Attention is paid to the pallor of the skin in combination with the cyanotic coloring of the cheeks( "mitral blush"), swelling of the legs and feet, an increase in the abdomen. The lowered arterial pressure in combination with a weak frequent pulse is determined. When listening to the organs of the chest( auscultation), pathological noises and tones( the so-called "quail rhythm") are revealed, due to the blood flow through the narrowed hole, wheezing in the lungs. When palpation of the abdomen( palpation) is determined by the increase in the liver.

2. Laboratory methods of examination. In the clinical analysis of blood, it is possible to detect an increase in the level of white blood cells( white blood cells) due to an active rheumatic process in the body, a violation of the blood coagulation system. In the general analysis of urine there are pathological indices, indicating a violation of kidney function( protein, white blood cells, etc.).In the biochemical analysis of blood, indices of liver and kidney function( bilirubin, urea, creatinine, etc.) are determined. Also in the blood, methods of immunological research can reveal changes characteristic of rheumatism( C-reactive protein, antistreptolysin, antistreptokinase, etc.).

3. Instrumental methods of research.
- when performing ECG, changes are recorded that are characteristic of left atrial and right ventricular hypertrophy, heart rhythm disturbances.
- 24-hour ECG monitoring allows detecting possible cardiac rhythm disturbances in normal household activity that were not registered when a single ECG was performed at rest.
- radiography of chest organs determines stagnation in the lungs, changes in the configuration of the heart due to the expansion of its chambers.
- echocardiography( ultrasound of the heart) is performed to visualize the internal formations of the heart, reveals a change in the thickness and mobility of valve flaps, narrowing its opening, and allows measuring the area of ​​constriction. Also, with ECHO-KG, the doctor determines the degree of severity of hemodynamic disorders( increased left atrial pressure, hypertrophy and dilatation( expansion) of the left atrium and right ventricle), assesses the degree of disturbances of blood flow from the left ventricle to the aorta( ejection fraction, stroke volume).

A slight stenosis( more than 3 sq. Cm.), Mild stenosis( 2.0-2.9 sq. Cm), severe stenosis( 1.0 - 1.9 sq. Cm.), Critical stenosis( less than 1.0 sq. Cm.), Acute stenosis).The measurement of this indicator is important in terms of managing the patient, in particular, the definition of surgical tactics, since stenosis with an area of ​​less than 1.5 square meters.see is a direct indication of the operation.

- before surgical treatment or in cases of unclear diagnosis, cardiac catheterization can be indicated, in which the pressure in the heart is measured and the pressure difference in the left atrium and ventricle is determined.

The image obtained by echocardiography shows thickened mitral valves

Treatment of stenosis of the mitral valve

The treatment tactics with the choice of the method of treatment( medical, surgical or combination thereof) are determined individually for each patient depending on the degree of stenosis and clinical stagedisease.

So, in the 1st stage( compensation) in the absence of clinical manifestations and with a degree of narrowing of the atrioventricular aperture on the left more than 3 square meters.see the operation is not shown, and drug treatment is aimed at preventing blood stagnation in the blood vessels( diuretics, long-acting nitroglycerin modifications - nitrosorbide, monochinke).

Stages 2 and 3( subcompensation and initial manifestations of decompensation), especially in combination with a degree of stenosis of less than 1.5 square meters.see are indications for surgical treatment with a constant intake of medications.

In stage 4( severe decompensation), the operation can prolong the life of the patient, but not for long, therefore, as a rule, at this stage, surgical treatment is not applied because of the high degree of postoperative risk.

In the 5th stage( terminal), the operation is contraindicated because of severe hemodynamic disorders and changes in the internal organs, so only medical treatment with a palliative purpose is used( to ease the patient's pain as much as possible).

Drug therapy for mitral valve stenosis reduces to the appointment of the following groups of drugs:

- cardiac glycosides( korglikon, strophanthin, digitoxin, etc.) are used in patients with reduced right ventricular contractility, and also in the presence of a constant form of atrial fibrillation in the patient.
- B - adrenoblockers( carvedilol, bisoprolol, nebilet, etc.) are used to reduce the rhythm in the occurrence of paroxysms( attacks) of atrial fibrillation or at its constant form.
- Diuretics( diuretics - indapamide, veroshpiron, furosemide, spironolactone, etc.) are necessary in order to "unload" a small circle of blood circulation( vessels of the lungs) and reduce the stagnation of blood in the internal organs.
- ACE inhibitors( fosinopril, ramipril, lisinopril, captopril, etc.) and angiotensin receptor blockers 11( valsartan, losartan, etc.) have cardioprotective properties - they protect the heart cells from the damaging effects of various substances( for example, lipid peroxidation products)with many, and cardiological including diseases.
- Nitrates( nitroglycerin, nitrosorbide, retard cardid, monochinkwe, etc.) are used as peripheral vasodilators, that is, they dilate the vessels on the periphery of the body into which blood from the lungs vessels rushes, and thus reduce the dyspnea.
- Antiaggregants and anticoagulants( thromboass, cardiomagnesium, aspirin, heparin, etc.) are used to prevent the formation of blood clots in the heart and blood vessels, especially in atrial fibrillation and in the postoperative period.
- Antibiotics( penicillins) and anti-inflammatory drugs( ibuprofen, diclofenac, nimesulide, etc.) are mandatory in the acute phase of rheumatism, as well as in repeated rheumatic attacks.

Exemplary treatment regimen for a patient with mitral stenosis with minimal clinical manifestations, without atrial fibrillation( taking daily medications for a long time, with possible replacement of the drug or correction of its dosage by the attending physician depending on the severity of the symptoms):

- noliprel A forte 5 mg /1.25 mg( 5 mg perindopril + 1. 25 mg indapamide) in the morning,
- concor( bisoprolol) 10 mg once a day in the morning,
- tromboAss 100 mg after lunch,
- nitromite 1 - 2 doses under the tongue with painin the heart or in dyspnea,
- monochinkve 20 mg 2 times a day - 2 weeks, then nitrosorbide 10 mg for 20 minutes before exercise.

The surgical methods of treatment include:
- balloon valvuloplasty - a probe with a miniature balloon at the end that inflates at the time it passes through the atrioventricular orifice is inserted through the vessels to the heart, and the septa of the valve flaps is broken,
is an open commissurotomy - an open heart surgery is performedwith access to the mitral valve and dissection of its adhesions,
- mitral valve prosthetics - is more often used in the combination of stenosis and valve failure and exerciseS THE by replacing her with an artificial valve( mechanical or biological implant).

Contraindications for operation:

- stage of severe decompensation( ejection fraction less than 20%) and terminal stage of defect flow;
- acute infectious diseases;
- common somatic diseases in decompensation stage( bronchial asthma, diabetes mellitus, etc.)
- acute myocardial infarction and other acute diseases of the cardiovascular system( hypertensive crisis, stroke, first arising complex rhythm disturbances, etc.).

Lifestyle for mitral stenosis

For a patient with this disease, it is necessary to observe the following recommendations: to eat well and properly, limit the amount of fluid and table salt, set an adequate mode of work and rest, sleep well, limit physical activity and eliminate stressful situations,in the open air.

A pregnant woman needs to be registered in a women's consultation in time to decide on the prolongation of pregnancy and the choice of the method of delivery( usually by caesarean section).With compensated malformation, pregnancy is normal, but with severe hemodynamic disorders, pregnancy is contraindicated.

Complications without treatment

Without treatment, there is imminent progression of hemodynamic disorders, expressed stagnant phenomena in the lungs and other organs, which leads to the development of complications and death. Complications of this disease are such as pulmonary embolism( especially in patients with atrial fibrillation), pulmonary edema, pulmonary hemorrhage, acute heart failure.

Complications of operation

Both in the early and late postoperative periods, there is also the possibility of complications:

• infective endocarditis( development of bacterial inflammation on the valve flaps, including biological artificial);
• the formation of thrombi as a result of the work of a mechanical prosthesis with the development of thromboembolism - detachment of a thrombus and its ejection into the vessels of the lungs, brain, abdominal cavity;
• degeneration( destruction) of an artificial bio-valve with repeated development of hemodynamic disorders.

The physician's tactic is reduced to regular examination of patients by echocardiography, blood coagulation monitoring, lifetime administration of anticoagulants and antiplatelet agents( clopidogrel, warfarin, dipyridamole, quarantil, aspirin, etc.), antibiotic therapy for infectious diseases, cavitary operations, minimal medical and diagnostic proceduresin gynecology, urology, dentistry, etc.

Forecast

The prognosis of mitral stenosis without treatment is unfavorable, since in the outcome of the disease we areAET death. The average age of patients with such a defect is 45 to 50 years. To significantly prolong life and improve its quality, cardiosurgical treatment( as a method of radical correction of anatomical and functional changes) in combination with regular intake of medications is possible.

Doctor therapist Sazykina O.Yu.