Mitral stenosis: causes, symptoms, treatment. Symptoms, treatment and prevention of mitral stenosis

The frequency of mitral stenosis is 44-68% of all defects, it develops mainly in women. Occurs, as a rule, due to long-term rheumatic endocarditis; very rarely it is congenital or occurs as a result of septic endocarditis. The narrowing of the left atrioventricular orifice occurs when the leaflets of the left atrioventricular (mitral) valve are fused, their seal and thickening, as well as when the tendon filaments are shortened and thickened. As a result of these changes, the valve takes the form of a funnel or diaphragm with a slotted hole in the middle. Of less importance in the origin of stenosis is the cicatricial-inflammatory narrowing of the valve ring. With the long-term existence of a defect in the tissue of the affected valve, lime may be deposited.

Hemodynamics. With mitral stenosis, hemodynamics is significantly impaired in the case of a significant narrowing of the atrioventricular orifice, when its cross section decreases from 4–6 cm 2 (normal) to 0.5–1 cm 2. During diastole, blood does not have time to move from the left atrium to the left ventricle, and some blood remains in the atrium, supplemented by blood flow from the pulmonary veins. There is an overflow of the left atrium and an increase in pressure in it, which is initially compensated by increased contraction of the atrium and its hypertrophy. However, the myocardium of the left atrium is too weak to compensate for the pronounced narrowing of the mitral orifice for a long time, so its contractility decreases rather quickly, the atrium expands even more, and the pressure in it becomes even higher. This entails an increase in pressure in the pulmonary veins, a reflex spasm of the pulmonary arterioles and an increase in pressure in the pulmonary artery, requiring more work of the right ventricle. Over time, the right ventricle hypertrophies (Figure 5). The left ventricle with mitral stenosis receives little blood, performs less than normal work, so its size is somewhat reduced.

Figure 5. Intracardiac hemodynamics in normal conditions (a) and in stenosis of the left atrioventricular orifice (b).

Diagnostics. In the presence of congestion in the pulmonary circulation, patients develop shortness of breath, palpitations during exercise, sometimes pain in the heart, cough and hemoptysis. On examination, acrocyanosis is often noted; a blush with a cyanotic tinge (faсies mitrale) is characteristic. If a defect develops in childhood, then there is often a lag in physical development, infantilism (“mitral nanism”).

Some Clinical signs mitral stenosis:

Pulsus differens - appears when the left atrium is compressed by the left subclavian artery.

Anisocoria is the result of compression of the sympathetic trunk by an enlarged left atrium.

At examining the area of the heart often noticeable cardiac impulse due to expansion and hypertrophy of the right ventricle. The apex beat is not strengthened, on palpation in its area, the so-called diastolic cat's purr (presystolic trembling) is detected, i.e. low-frequency diastolic noise is defined.

Percussion find the expansion of the zone of cardiac dullness up and to the right due to hypertrophy of the left atrium and right ventricle. The heart acquires a mitral configuration.

At auscultation of the heart very characteristic changes characteristic of mitral stenosis are found. Since little blood enters the left ventricle and its contraction occurs quickly, the I tone at the apex becomes loud, popping. In the same place, after the second tone, it is possible to listen to an additional tone-tone of opening mitral valve. Loud tone I, tone II and the opening tone of the mitral valve creates a melody typical of mitral stenosis, called the “quail rhythm”. With an increase in pressure in the pulmonary circulation, an accent of the II tone appears over the pulmonary trunk.

Mitral stenosis is characterized by a diastolic murmur, since there is a narrowing in the course of blood flow from the left atrium to the ventricle during diastole. This murmur may occur immediately after the mitral valve opening tone, because due to the difference in pressure in the atrium and ventricle, the blood flow velocity will be higher at the beginning of diastole; as the pressure equalizes, the noise will decrease.

Often, noise appears at the end of diastole just before systole itself - presystolic murmur, which occurs when blood flow accelerates at the end of ventricular diastole due to the beginning of atrial systole. Diastolic murmur in mitral stenosis can be heard throughout the entire diastole, increasing before systole and directly merging with I clapping tone.

Pulse with mitral stenosis, it may be different on the right and left hands. Since, with significant hypertrophy of the left atrium, the left subclavian artery is compressed, the filling of the pulse on the left decreases (pulsus differens). With a decrease in the filling of the left ventricle and a decrease in stroke volume, the pulse becomes small - pulsus parvus. Mitral stenosis is often complicated by atrial fibrillation, in these cases the pulse is arrhythmic.

Arterial pressure usually remains normal, sometimes decreases slightly systolic pressure and increased diastolic.

X-ray an increase in the left atrium, characteristic of this defect, is revealed, which leads to the disappearance of the “waist” of the heart and the appearance of its mitral configuration. In the first oblique position, an increase in the left atrium is determined by the deviation of the esophagus, which is clearly visible when the patient takes a suspension of barium sulfate . With an increase in pressure in the pulmonary circulation, bulging of the arch of the pulmonary artery and hypertrophy of the right ventricle are radiologically noted. Sometimes on the roentgenogram the calcification of the left atrioventricular valve is found. With prolonged hypertension of the vessels of the pulmonary circulation, pneumosclerosis develops, which can also be detected by X-ray examination.

ECG with mitral stenosis reflects hypertrophy of the left atrium and right ventricle; the size and duration of the P wave increases, especially in I and II standard leads, the electrical axis of the heart deviates to the right, a high tooth appears R in the right chest leads and a pronounced tooth S in the left chest.

echocardiography with mitral stenosis, it acquires a number of characteristic features (Figure 6):

Figure 6. Echocardiogram in left atrioventricular stenosis. The movement of the mitral valve leaflets is U-shaped.

HS - chest; PSVC - anterior wall of the right ventricle; RV - right ventricle; IVS - interventricular septum; LV left ventricle; PSMK - anterior leaflet of the mitral valve; ZSLZh - posterior wall of the left ventricle; ZSMK - posterior leaflet of the mitral valve.

1. Peak A sharply decreases or disappears, reflecting the maximum opening of the leaflets of the left atrioventricular valve during atrial systole.

2. The rate of diastolic occlusion of the anterior leaflet of the valve decreases, which leads to a decrease in the slope of the E-f interval.

3. The movement of the valve leaflets changes. If normally the valves diverge in opposite directions during diastole (the anterior leaflet to the anterior wall, the posterior one to the posterior one), then with stenosis, their movements become unidirectional, since due to the fusion of the commissures, the more massive anterior leaflet pulls the posterior one. The movement of the leaflets on echocardiography acquires a U-shaped configuration. In addition, with the help of echocardiography, it is possible to detect an increase in the left atrium, a change in the valve leaflets (fibrosis, calcification).

With mitral stenosis, stagnation occurs early in the pulmonary circulation, which requires hard work right stomach. Therefore, the weakening of the contractility of the right ventricle and venous congestion in the systemic circulation develop with mitral stenosis earlier and more often than with mitral valve insufficiency. The weakening of the myocardium of the right ventricle and its expansion is sometimes accompanied by the appearance of relative insufficiency of the right atrioventricular (tricuspid) valve. In addition, prolonged venous congestion in the pulmonary circulation with mitral stenosis over time leads to vascular sclerosis and proliferation connective tissue in the lungs. A second, pulmonary, barrier is created for the movement of blood through the vessels of the small circle, which further complicates the work of the right ventricle.

During mitral stenosis, 3 periods are distinguished:

Compensation.

Pulmonary hypertension, right ventricular hypertrophy.

Right ventricular failure (stagnation in the systemic circulation).

Complications of mitral stenosis:

Acute left ventricular failure (cardiac asthma, pulmonary edema).

Chronic cardiovascular insufficiency (stagnation in the lungs).

Rhythm disturbances (often atrial fibrillation).

thromboembolic syndrome.

Attachment of infective endocarditis.

Prosthesis failure or restenosis in commissurotomy.

There are 3 degrees of MC calcification:

Calcium is located along the free edges of the valves or in the commissures in separate nodes;

Leaflet calcification without transition to the annulus fibrosus;

Transition of calcium masses to the annulus fibrosus and surrounding structures.

Differential Diagnosis mitral stenosis:

Myxoma of the heart (left atrium or ventricle).

Congenital defect - Lutembashe's syndrome (mitral valve stenosis + ASD).

Nonspecific aorto-arteritis.

Treatment

Heart failure

At S=1.0-1.5 cm 2 limitation of heavy loads, and at<1.0 см 2 – только небольшие нагрузки.

Diuretics - for congestion

Cardiac glycosides - for systolic dysfunction

ACE inhibitors carefully, because. vasodilators may decrease cardiac output

Surgical correction of the defect

Valve prosthetics

Balloon valvuloplasty

Indications for balloon valvuloplasty (ACC/ AHA, 2006)

Patients with moderate/severe stenosis (£1.5 cm2) and valve suitable for valvotomy +

Heart failure 2-4 FC.
Asymptomatic with pulmonary hypertension (>50 mmHg) or recent atrial fibrillation.
Heart failure 3-4 FC with calcified valves and high risk of surgery.

Indications for valve replacement

Patients not eligible for balloon valvotomy +

Heart failure 3-4 FC with moderate or severe stenosis (£1.5 cm 2).
Patients with severe stenosis (£1.0 cm 2), severe pulmonary hypertension (> 60 mm Hg. Art.) and heart failure 1-2 FC.

Replacement of the valve with a mechanical or biological, or xenoprosthesis.

Mitral stenosis is a narrowing of the mitral orifice that prevents blood from flowing from the left atrium into the left ventricle. Most common cause- rheumatic fever. The symptoms are the same as in heart failure. Objectively determine the opening tone and diastolic murmur. The diagnosis is established by physical examination and echocardiography. The prognosis is favorable. Medical treatment for mitral stenosis includes diuretics, beta-blockers or heart rate-lowering calcium channel blockers, and anticoagulants. Surgical treatment of more severe mitral stenosis consists of balloon valvotomy, commissurotomy, or valve replacement.

ICD-10 code

I05.0 Mitral stenosis

Epidemiology

Almost always, mitral stenosis is a consequence of acute rheumatic fever. The incidence varies significantly: in developed countries, 1-2 cases per 100,000 population are observed, while in developing countries (for example, in India), rheumatic mitral defects are observed in 100-150 cases per 100,000 population.

Causes of mitral stenosis

Mitral stenosis is almost always the result of acute rheumatic fever (RF). Isolated, "pure" mitral stenosis occurs in 40% of all patients with rheumatic heart disease; in other cases - a combination with insufficiency and damage to other valves. To the number rare causes mitral stenosis include rheumatic diseases (rheumatoid arthritis, systemic lupus erythematosus) and calcification of the mitral annulus.

Pathogenesis

In rheumatic mitral stenosis, thickening, fibrosis and calcification of the valve leaflets, fusion along commissures with frequent involvement of chords are observed. Normally, the area of the mitral orifice is 4-6 cm 2, and the pressure in the cavity of the left atrium does not exceed 5 mm Hg. With narrowing of the left atrioventricular orifice to 2.5 cm 2, an obstruction occurs to the normal blood flow from the left atrium to the left ventricle and the valvular pressure gradient begins to grow. As a result, the pressure in the cavity of the left atrium increases to 20-25 mm Hg. The resulting pressure gradient between the left atrium and the left ventricle promotes the movement of blood through the narrowed opening.

As the stenosis progresses, the transmitral pressure gradient increases to maintain diastolic blood flow through the valve. In accordance with the Gorlin formula, the area of the mitral valve (5MK) is determined by the values of the transmitral gradient (DM) and mitral blood flow (MK):

BMK - MK / 37.7 ∆DM

The main hemodynamic consequence of mitral heart disease is congestion in the pulmonary circulation (ICC). With a moderate increase in pressure in the left atrium (no more than 25-30 mm Hg), blood flow in the ICC becomes difficult. The pressure in the pulmonary veins increases and is transmitted through the capillaries to the pulmonary artery, resulting in the development of venous (or passive) pulmonary hypertension. With an increase in pressure in the left atrium more than 25-30 mm. Hg increases the risk of rupture of pulmonary capillaries and the development of alveolar pulmonary edema. To prevent these complications, a protective reflex spasm of the pulmonary arterioles occurs. As a result, the blood flow to the cell capillaries from the right ventricle decreases, but the pressure in the pulmonary artery(arterial, or active, pulmonary hypertension develops).

In the early stages of the course of the defect, the pressure in the pulmonary artery increases only during physical or emotional stress, when blood flow in the ICC should increase. Late stages of the disease are characterized by high values of pressure in the pulmonary artery even at rest and an even greater increase during exercise. The long-term existence of pulmonary hypertension is accompanied by the development of proliferative and sclerotic processes in the wall of the arterioles of the ICC, which are gradually obliterated. Despite the fact that the occurrence of arterial pulmonary hypertension can be considered as a compensatory mechanism, due to a decrease in capillary blood flow, the diffuse capacity of the lungs also drops sharply, especially during exercise, i.e. the mechanism of progression of pulmonary hypertension due to hypoxemia is switched on. Alveolar hypoxia causes pulmonary vasoconstriction through a direct and indirect mechanism. The direct effect of hypoxia is associated with the depolarization of vascular smooth muscle cells (mediated by a change in the function of potassium channels in cell membranes) and their contraction. indirect mechanism consists in the effect on the vascular wall of endogenous mediators (such as leukotrienes, histamine, serotonin, angiotensin II and catecholamines). Chronic hypoxemia leads to endothelial dysfunction, which is accompanied by a decrease in the production of endogenous relaxing factors, including prostacyclin, prostaglandin E2 and nitric oxide. Due to the long-term existence of endothelial dysfunction, pulmonary vascular obliteration and endothelial damage occur, which in turn leads to increased blood clotting, proliferation of smooth muscle cells with a tendency to thrombosis in situ and an increased risk of thrombotic complications with the development of subsequent chronic post-thrombotic pulmonary hypertension.

The causes of pulmonary hypertension in mitral defects, including mitral stenosis, are:

passive transfer of pressure from the left atrium to the pulmonary venous system;
spasm of pulmonary arterioles in response to increased pressure in the pulmonary veins;
swelling of the walls of small pulmonary vessels;
obliteration of pulmonary vessels with damage to the endothelium.

Until now, the mechanism of progression of mitral stenosis remains unclear. A number of authors consider the current valvulitis (often subclinical) to be the main factor, others assign the leading role to the traumatization of valvular structures by turbulent blood flow with the imposition of thrombotic masses on the valves, which underlies the narrowing of the mitral orifice.

Symptoms of mitral stenosis

Symptoms of mitral stenosis do not correlate well with the severity of the disease, since in most cases the pathology progresses slowly, and patients reduce their activity without noticing it. Many patients are asymptomatic until pregnancy occurs or atrial fibrillation develops. Initial symptoms are usually signs of heart failure (dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnoea, fatigue). They usually appear 15 to 40 years after an episode of rheumatic fever, but in developing countries even children can develop symptoms. Paroxysmal or persistent atrial fibrillation exacerbates existing diastolic dysfunction, causing pulmonary edema and acute dyspnea if the frequency ventricular contractions poorly controlled.

Atrial fibrillation may also present with palpitations; in 15% of patients not receiving anticoagulants, this causes systemic embolism with limb ischemia or stroke.

Rarer symptoms include hemoptysis due to rupture of small pulmonary vessels and pulmonary edema (especially during pregnancy when blood volume increases); dysphonia due to compression of the left recurrent laryngeal nerve by the dilated left atrium or pulmonary artery (Ortner's syndrome); pulmonary symptoms arterial hypertension and right ventricular failure.

The first symptoms of mitral stenosis

Mitral orifice area >1.5 cm 2 may be asymptomatic, but an increase in transmitral blood flow or a decrease in diastolic filling time leads to sharp increase pressure in the left atrium and the appearance of symptoms. Provoking (trigger) factors of decompensation: physical activity, emotional stress, atrial fibrillation, pregnancy.

The first symptom of mitral stenosis (approximately 20% of cases) may be an embolic event, most often a stroke with the development of persistent neurological deficit in 30-40% of patients. One third of thromboembolism develops within 1 month after the development of atrial fibrillation, two thirds - during the first year. The source of embolism is usually thrombi located in the left atrium, especially in its ear. In addition to strokes, emboli in the spleen, kidneys, and peripheral arteries are possible.

In sinus rhythm, the risk of embolism is determined by:

age;
thrombosis of the left atrium;
mitral orifice area;
associated aortic insufficiency.

With a permanent form of atrial fibrillation, the risk of embolism increases significantly, especially if the patient has already had similar complications in the anamnesis. Spontaneous contrast enhancement of the left atrium during ventricular echocardiography with esophageal echocardiography is also considered a risk factor for systemic embolism.

With an increase in pressure in the ICC (especially at the stage of passive pulmonary hypertension), there are complaints of shortness of breath during exercise. With the progression of stenosis, shortness of breath occurs at lower loads. It should be remembered that complaints of shortness of breath may be absent even with undoubted pulmonary hypertension, since the patient may lead a sedentary lifestyle or subconsciously limit daily activities. physical activity. Paroxysmal nocturnal dyspnea occurs as a result of stagnation of blood in the ICC when the patient is lying down as a manifestation of interstitial pulmonary edema and a sharp increase in blood pressure in the vessels of the ICC. Due to increased pressure in the pulmonary capillaries and sweating of plasma and red blood cells into the lumen of the alveoli, hemoptysis may develop.

Patients often also complain of increased fatigue, palpitations, interruptions in the work of the heart. There may be transient hoarseness of the voice (Ortner's syndrome). This syndrome occurs as a result of compression recurrent nerve enlarged left atrium.

Patients with mitral stenosis often experience chest pain, reminiscent of angina pectoris. Their most likely causes are pulmonary hypertension and right ventricular hypertrophy.

With severe decompensation, facies mitralis (bluish-pink blush on the cheeks, which is associated with a decrease in ejection fraction, systemic vasoconstriction and right-sided heart failure), epigastric pulsation and signs of right ventricular heart failure can be observed.

Inspection and auscultation

On examination and palpation, it is possible to detect defined I (S1) and II (S2) heart sounds. S1 is best palpated at the apex, and S2 at the left upper edge of the sternum. The pulmonary component of S3 (P) is responsible for the impulse and is the result of pulmonary arterial hypertension. Visible RV pulsation palpable at the left sternal border may accompany jugular vein swelling if pulmonary arterial hypertension exists and right ventricular diastolic dysfunction develops.

The apex beat in mitral stenosis is most often normal or reduced, reflecting normal left ventricular function and decreased volume. Palpable I tone in the precordial region indicates the preserved mobility of the anterior leaflet of the mitral valve. In the position of the pale side, diastolic trembling can be felt. With the development of pulmonary hypertension, a cardiac impulse is noted along the right border of the sternum.

The auscultatory picture in mitral stenosis is quite characteristic and includes the following features:

enhanced (clapping) I tone, the intensity of which decreases as the stenosis progresses;
mitral valve opening tone following tone II, disappearing with valve calcification;
diastolic murmur with a maximum at the apex (mesodiastolic, presystolic, pandiastolic), which must be heard in the position on the left side.

Auscultatory determine loud S 1, caused by the leaflets of the stenotic mitral valve, closing abruptly, like an "inflating" sail; this phenomenon is heard best at the top. A split S is also usually heard with an increased P due to pulmonary arterial hypertension. The most striking is the early diastolic click of the opening of the valves into the left ventricle (LV), which is loudest at the left lower edge of the sternum. It is accompanied by a low, waxing, rumbling diastolic murmur that is heard best with a funneled stethoscope at the apex of the heart (or over a palpable apex beat) at the end of exhalation when the patient lies on the left side. The opening tone may be soft or absent if the mitral valve is sclerosed, fibrotic, or indurated. The click moves closer to P (increasing the duration of the murmur) as the severity of mitral stenosis increases and pressure in the left atrium increases. The diastolic murmur increases during the Valsalva maneuver (when blood flows into the left atrium), after exercise, and when squatting and shaking hands. This may be less pronounced if an enlarged right ventricle displaces the left ventricle posteriorly and when other disorders (pulmonary arterial hypertension, right valve disease, atrial fibrillation with rapid ventricular rate) reduce blood flow through the mitral valve. Presystolic enhancement is associated with narrowing of the mitral valve opening during left ventricular contraction, which also occurs during atrial fibrillation, but only at the end of a short diastole, when the pressure in the left atrium is still high.

Next diastolic murmurs may be combined with the murmur of mitral stenosis:

Graham Still's murmur (a soft, decreasing diastolic murmur heard best over the left side of the sternum and caused by regurgitation at the pulmonic valve due to severe pulmonary hypertension);
Austin Flint murmur (middle or late diastolic murmur heard at the apex of the heart and caused by the flow of aortic regurgitation on the mitral valve leaflets) when rheumatic carditis affects the mitral and aortic valves.

Disorders that cause diastolic murmurs that mimic a mitral stenosis murmur include mitral regurgitation (due to large flow through the mitral orifice), aortic regurgitation (causing an Austin Flint murmur), and atrial myxoma (which causes a murmur that typically varies in volume and position with each heartbeat).

Mitral stenosis can cause cor pulmonale symptoms. classic sign facies mitralis(hyperemia of the skin with a plum tint in the area of the zygomatic bone) occurs only when functional state heart rate is low, and pulmonary hypertension is pronounced. Causes facies mitralis are vasodilatation of the skin and chronic hypoxemia.

Sometimes the first symptoms of mitral stenosis are manifestations of embolic stroke or endocarditis. The latter rarely occurs with mitral stenosis that is not accompanied by mitral regurgitation.

Clinical manifestations of pulmonary hypertension in mitral stenosis

The first symptoms of pulmonary hypertension are nonspecific, and this greatly complicates its early diagnosis.

Shortness of breath is due to both the presence of pulmonary hypertension and the inability of the heart to increase cardiac output during exercise. Dyspnea is usually of an inspiratory nature, at the onset of the disease it is intermittent, occurring only with moderate physical exertion, then, as pressure in the pulmonary artery increases, it appears with minimal physical exertion, and may be present at rest. With high pulmonary hypertension, a dry cough may occur. It should be remembered that patients may subconsciously limit physical activity, adapting to a certain lifestyle, so complaints of shortness of breath are sometimes absent even with undoubted pulmonary hypertension.

Weakness, increased fatigue - the causes of these complaints may be a fixed cardiac output (the amount of blood ejected into the aorta does not increase in response to physical activity), increased pulmonary vascular resistance, as well as a decrease in perfusion of peripheral organs and skeletal muscle caused by impaired peripheral circulation.

Dizziness and fainting are caused by hypoxic encephalopathy, usually provoked by physical activity.

Persistent pain behind the sternum and to the left of it is due to overstretching of the pulmonary artery, as well as insufficient blood supply to the hypertrophied myocardium (relative coronary insufficiency).

Interruptions in the work of the heart and heartbeat. These symptoms are associated with the frequent occurrence of atrial fibrillation.

Hemoptysis occurs due to rupture of the pulmonary-bronchial anastomoses under the influence of high venous pulmonary hypertension, and may also be due to increased pressure in the pulmonary capillaries and sweating of plasma and erythrocytes into the lumen of the alveoli. Hemoptysis can also be a symptom of pulmonary embolism and pulmonary infarction.

To characterize the severity of the course of pulmonary hypertension, use functional classification proposed by WHO for patients with insufficient blood supply:

class I - patients with pulmonary hypertension, but without limitation of physical activity. Ordinary physical activity does not cause shortness of breath, weakness, chest pain, dizziness;
class II - patients with pulmonary hypertension, leading to some decrease in physical activity. At rest, they feel comfortable, but ordinary physical activity is accompanied by the appearance of shortness of breath, weakness, chest pain, dizziness;
class III - patients with pulmonary hypertension, leading to severe limitation of physical activity. At rest, they feel comfortable, but little physical activity causes shortness of breath, weakness, chest pain, dizziness;
class IV - patients with pulmonary hypertension who cannot perform any physical activity without the listed symptoms. Shortness of breath or weakness is sometimes present even at rest, and discomfort increases with minimal exertion.

Forms

Mitral stenosis is classified according to severity (ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography).

Classification of mitral stenosis by degree

In mitral stenosis, the leaflets of the mitral valve become thickened and immobile, and the mitral orifice narrows due to fusion of the commissures. The most common cause is rheumatic fever, although most patients have no memory of the illness. Rarer causes include congenital mitral stenosis, septic endocarditis, systemic lupus erythematosus, atrial myxoma, rheumatoid arthritis, malignant carcinoid syndrome with atrial shunting from right to left. If the valve cannot close completely, mitral regurgitation (MP) may exist concurrently with mitral stenosis. Many patients with mitral stenosis due to rheumatic fever also have aortic regurgitation.

The normal area of the mitral valve opening is 4-6 cm 2 . An area of 1-2 cm2 is indicative of moderate or severe mitral stenosis and often causes clinical symptoms on exertion. Square

Valvular pathology with left atrial dilatation predisposes to the development of atrial fibrillation (AF) and thromboembolism.

Complications and consequences

Pulmonary arterial hypertension, atrial fibrillation, and thromboembolism are common complications.

Diagnosis of mitral stenosis

The preliminary diagnosis is made clinically and confirmed by echocardiography. Two-dimensional echocardiography provides information on the degree of valvular calcification, the size of the left atrium and stenosis. Doppler echocardiography provides information on the transvalvular gradient and pulmonary artery pressure. Transesophageal echocardiography can be used to detect or rule out small left atrial clots, especially in the atrial appendage, which are often not detectable on transthoracic examination.

Radiography chest usually shows flattening of the left border of the heart due to a dilated left atrial appendage. The main trunk of the pulmonary artery may be visible; the diameter of the descending right pulmonary artery exceeds 16 mm if pulmonary hypertension is expressed. Pulmonary veins upper lobes may be dilated because the veins of the lower lobes are compressed, causing plethora of the upper lobes. A double shadow of an enlarged left atrium can be determined along the right contour of the heart. Horizontal lines in the lower posterior lung fields (Kerley lines) indicate interstitial edema associated with high pressure in the left atrium.

Cardiac catheterization is indicated only for preoperative detection of CAD: left atrial enlargement, pulmonary artery pressure, and valve area can be assessed.

The patient's ECG is characterized by the appearance of P-mitrale (wide, with a notch PQ), deviation electrical axis heart to the right, especially with the development of pulmonary hypertension, as well as hypertrophy of the right (with isolated mitral stenosis) and left (in combination with mitral insufficiency) ventricles.

The severity of stenosis is assessed using a Doppler study. The mean transmitral pressure gradient and the area of the mitral valve can be determined quite accurately using continuous wave technology. Of great importance is the assessment of the degree of pulmonary hypertension, as well as concomitant mitral and aortic regurgitation.

Additional information can be obtained using a stress test (stress echocardiography) with registration of the transmitral and tricuspid blood flow. With a mitral valve area of 50 mm. rt. Art. (after exercise) it is necessary to consider the issue of balloon mitral valvuloplasty.

In addition, spontaneous echo contrast during transesophageal echocardiography is an independent predictor of embolic complications in patients with mitral stenosis.

Transesophageal echocardiography allows to clarify the presence or absence of a left atrial thrombus, to clarify the degree of mitral regurgitation in the planned balloon mitral valvuloplasty. In addition, a transverse study allows you to accurately assess the state of the valvular apparatus and the severity of changes in the subvalvular structures, as well as assess the likelihood of restenosis.

cardiac catheterization and main vessels carried out in cases where surgical intervention is planned, and the data of non-invasive tests do not give an unambiguous result. Direct measurement of pressure in the left atrium and left ventricle requires transseptal catheterization, which is associated with unjustified risk. By indirect method measurement of pressure in the left atrium serves to determine the pressure of pulmonary artery wedge.

Differential Diagnosis

At careful examination diagnosis mitral defect usually no doubt.

Mitral stenosis is also differentiated with left atrial myxoma, other valvular defects (mitral insufficiency, tricuspid valve stenosis), atrial septal defect, pulmonary vein stenosis, congenital mitral stenosis.

Examples of the formulation of the diagnosis

Rheumatic heart disease. Combined mitral defect with a predominance of stenosis of the left atrioventricular orifice III degree. Atrial fibrillation, permanent form, tachysystole. Moderate pulmonary hypertension. NK PB stage, III FC.
Rheumatic heart disease. Combined mitral defect. Mitral valve replacement (Medinzh - 23) from DD/MM/YY. NK stage IIA, II FC.

Treatment of mitral stenosis

The main goals of the treatment of patients with mitral stenosis are to improve the prognosis and increase life expectancy, alleviate the symptoms of the disease.

Medical treatment of mitral stenosis

Medical treatment can be used to control symptoms of mitral stenosis, for example in preparation for surgical intervention, Diuretics reduce left atrial pressure and relieve symptoms associated with congestion in the ICC. At the same time, diuretics should be used with caution, since a decrease in cardiac output is possible, beta-blockers and rhythm-reducing blockers of slow calcium channels (verapamil and diltiazem) reduce heart rate at rest and during exercise, improving filling of the left ventricle by lengthening diastole. These drugs can relieve exercise-related symptoms and are especially indicated for sinus tachycardia and atrial fibrillation.

Atrial fibrillation is a common complication of mitral stenosis, especially in older people. The risk of thromboembolism in the presence of atrial fibrillation is significantly increased (10-year survival - 25% of patients compared with 46% in patients with sinus rhythm).

Indirect anticoagulants (warfarin, starting dose 2.5-5.0 mg, controlled by INR) are indicated;

all patients with mitral stenosis complicated by atrial fibrillation (paroxysmal, persistent or permanent form);
patients with a history of embolic events, even with preserved sinus rhythm;
patients with a thrombus in the left atrium;
patients with severe mitral stenosis and those patients in whom the size of the left atrium is> 55 mm.

Treatment is carried out under the control of INR, the target levels of which are from 2 to 3. If the patient has embolic complications, despite ongoing anticoagulant treatment, it is recommended to add acetylsalicylic acid at a dose of 75-100 mg / day (an alternative is dipyridamole or clopidogrel). It should be noted that randomized controlled trials of the use of anticoagulants in patients with mitral stenosis have not been conducted, recommendations are based on extrapolation of data obtained in cohorts of patients with atrial fibrillation.

Since the appearance of atrial fibrillation in a patient with mitral stenosis is accompanied by decompensation, treatment aimed at slowing the ventricular rate is paramount. As already mentioned, beta-blockers, verapamil or diltiazem may be the drugs of choice. It is also possible to use digoxin, however, a narrow therapeutic interval and a worse ability to prevent an increase in the rhythm during exercise compared to beta-blockers limit its use. Electrical cardioversion also has limited use with persistent atrial fibrillation, since without surgical treatment of atrial fibrillation, the likelihood of recurrence is very high.

Surgical treatment of mitral stenosis

The main method of treatment for mitral stenosis is surgical, since there is currently no drug treatment that can slow down the progression of stenosis.

Patients with more severe symptoms or sign of pulmonary arterial hypertension require valvotomy, commissurotomy, or valve replacement.

The procedure of choice is percutaneous balloon mitral valvuloplasty. This is the main method of surgical treatment of mitral stenosis. In addition, open commissurotomy and mitral valve replacement are used.

Percutaneous balloon valvotomy is the preferred method for younger patients; older patients who cannot tolerate more invasive surgery, and patients without severe valvular calcification, subvalvular deformity, left atrial thrombi, or significant mitral regurgitation. In this procedure, under echocardiographic control, the balloon is passed through atrial septum from the right to the left atrium and inflate to separate the connected leaflets of the mitral valve. The results are comparable with the efficiency of more invasive operations. Complications are rare and include mitral regurgitation, embolism, left ventricular perforation, and atrial septal defect, which is likely to persist if the pressure difference between the atria is large.

Percutaneous balloon mitral valvuloplasty is indicated following groups patients with mitral orifice area less than 1.5 cm2:

decompensated patients with favorable characteristics for percutaneous mitral valvuloplasty (class I, level of evidence B);
decompensated patients with contraindications to surgical treatment or high operational risk (class I, level of evidence! and C);
in the event of a planned primary surgical correction malformation in patients with inappropriate valve morphology but with satisfactory clinical characteristics (class IIa, level of evidence C);
"asymptomatic" patients with suitable morphological and clinical characteristics, a high risk of thromboembolic complications or a high risk of hemodynamic decompensation;
with a history of embolic complications (class IIa, level of evidence C);
with the phenomenon of spontaneous echo contrast in the left atrium (class IIa, level of evidence C);
with constant or paroxysmal form atrial fibrillation (class IIa, level of evidence C);
with systolic pressure in the pulmonary artery more than 50 mm Hg. (class IIa, level of evidence C);
if major non-cardiac surgery is required (class IIa, level of evidence C);
in the case of pregnancy planning (class IIa, level of evidence C).

Suitable characteristics for performing percutaneous mitral valvuloplasty are the absence of the following:

clinical: elderly age, history of commissurotomy, functional class IV heart failure, atrial fibrillation, severe pulmonary hypertension;
morphological: any degree of mitral valve calcification assessed by fluorography, very small mitral valve area, severe tricuspid regurgitation.

Patients with severe subvalvular disease, valvular calcification, or thrombi in the left atrium may be candidates for commissurotomy, in which the attached mitral valve leaflets are separated by a dilator passed through the left atrium and left ventricle (closed commissurotomy), or by hand (open commissurotomy). Both operations require a thoracotomy. The choice depends on the surgical situation, the degree of fibrosis and calcification.

Mitral valve repair (open commissurotomy) or mitral valve replacement is performed for the following class I indications.

In the presence of heart failure III-IVFC and moderate or severe mitral stenosis in cases where:

it is impossible to perform mitral balloon valvuloplasty;
mitral balloon valvuloplasty is contraindicated due to left atrial thrombus despite anticoagulant use or due to concomitant moderate or severe mitral regurgitation;
valve morphology is not suitable for mitral balloon valvuloplasty.

With moderate or severe mitral stenosis and concomitant moderate or severe mitral regurgitation (valve replacement is indicated if repair is not possible).

Valve replacement is a last resort. It is prescribed to patients with mitral valve area

Mitral valve replacement is reasonable (class IIa indications) for severe mitral stenosis and severe pulmonary hypertension (systolic pressure in the pulmonary artery more than 60 mm Hg), symptoms of heart failure of I-II FC, if mitral balloon valvuloplasty or mitral valve repair is not suggested , Patients with mitral stenosis who do not have symptoms of decompensation should be examined annually. The examination includes the collection of complaints, anamnesis, examination, chest x-ray and ECG. If the patient's condition has changed over the previous period or, according to the results of the previous examination, there is severe mitral stenosis, it is indicated echocardiography. In all other cases, annual echocardiography is optional. If the patient complains of palpitations, 24-hour (Holter) ECG monitoring is recommended to detect paroxysms of atrial fibrillation.

During pregnancy, patients with mild and moderate stenosis can only receive drug treatment. The use of diuretics and beta-blockers is safe. If anticoagulant treatment is necessary, patients are prescribed heparin injections, since warfarin is contraindicated.

Prevention

The most important issue in the tactics of further management of patients with mitral stenosis is the prevention of relapses of rheumatic fever with long-acting penicillin preparations for life, as well as for all patients after surgical correction of the defect (including for the prevention of infective endocarditis). Benzathine benzylpenicillin is prescribed at a dose of 2.4 million units for adults and 1.2 million units for children intramuscularly once a month.

All patients with mitral stenosis are shown secondary prevention relapses of rheumatic fever. In addition, all patients are shown prophylaxis of infective endocarditis.

Asymptomatic patients only need prophylaxis for recurrent rheumatic fever [eg, intramuscular injections benzylpenicillin (penicillin G sodium salt sterile) 1.2 million units every 3 or 4 weeks] until the age of 25-30 years and prevention of endocarditis before risky procedures.

Forecast

The natural course of mitral stenosis varies, but the time between onset of symptoms and severe disability is approximately 7-9 years. The result of treatment depends on the patient's age, functional status, pulmonary arterial hypertension and the degree of atrial fibrillation. The results of valvotomy and commissurotomy are equivalent, both methods allow to restore the functioning of the valve in 95% of patients. However, over time, function deteriorates in most patients, and many require a second procedure. Risk factors for death are atrial fibrillation and pulmonary hypertension. The cause of death is usually heart failure or pulmonary or cerebrovascular embolism.

Mitral stenosis usually progresses slowly and proceeds with a long period of compensation. More than 80% of patients survive for 10 years in the absence of symptoms or moderate signs of CHF (FC I-II according to NUHA). The 10-year survival rate of decompensated and non-operated patients is much worse and does not exceed 15%. With the formation of severe pulmonary hypertension average term survival does not exceed 3 years.

Among organic diseases the leading role is occupied by congenital and acquired heart defects. Mitral valve lesions play essential in development serious violations hemodynamics and the occurrence of heart failure. One of the heart defects is mitral stenosis, or stenosis of the mitral valve of the heart, which can be combined with other valve pathologies and without treatment entails serious consequences.

Features of the disease

The mitral valve is located on the border of the left ventricle and the left atrium, representing a connective tissue formation with two thin, movable cusps. The most important task cusps is as follows: when blood through the left atrioventricular opening (mitral opening) flows from the atrium into the ventricle, the cusps open and release the flow. Then, as blood flows from the ventricle into the aorta, the valve closes, preventing blood from flowing back into the atrium. When the mitral valve in a healthy person closes, even the smallest gap does not remain, the reverse flow of blood (regurgitation) does not occur.

By different reasons in children and adults, connective tissue can be replaced by scar tissue, resulting in adhesions or scar bands on the annulus fibrosus of the mitral orifice or on the leaflets of the mitral valve itself. A disease from the group of heart defects that leads to narrowing of the atrioventricular orifice and disruption of diastolic blood flow in the left side of the heart is called mitral valve stenosis. Normally, the size of the mitral orifice is 4-6 cm2, and the diagnosis of stenosis is made when it narrows to smaller numbers, while symptoms begin to appear when it is narrowed to 2 cm2.

Stenosis of the mitral valve to the specified limits and more leads to the expulsion of the entire volume of blood from the left atrium into the left ventricle. Initially, compensation mechanisms begin to work, which cause an increase in atrial pressure from 5 to 25 mm Hg, systole lengthens, and left atrial hypertrophy gradually develops. All these phenomena make it easier for blood to flow through the narrowed atrioventricular orifice. But, despite the fact that initially hemodynamics does not change, mitral stenosis and pressure increase progress, inevitably leading to the appearance of pulmonary hypertension.

In the presence of pulmonary hypertension, the load on the right ventricle is high, and the emptying of the right atrium is difficult. As a result, there is a serious thickening of the right side of the heart and stretching of its chambers (dilation). Symptoms of heart failure develop, which causes hemodynamic decompensation in the systemic circulation. Due to reduced cardiac output, the entire body suffers, hypoxia of tissues and organs occurs. Without treatment, the patient dies of severe heart failure - its terminal stage.

Classification of pathology

First of all, the division of pathology is based on the area of the narrowed mitral orifice (in degrees):

The first degree is an area of more than 3 sq.cm.
The second degree is an area of 2.3-2.9 sq.cm.
Third degree - area 1.7-2.2 sq.cm.
The fourth degree is an area of 1.0-1.6 sq.cm.

The signs of the disease are not the same, depending on what stage the mitral stenosis passes in its development. The stage classification is as follows:

The stage of full compensation, or the first stage - the patient has no complaints, but objective signs are noticeable during auscultation of the heart.
The stage of onset of hemodynamic disorders, or the second stage. With physical activity, a characteristic clinic of the disease appears.
The stage of stagnation in the pulmonary circulation, or the third stage. Among other things, signs of stagnation begin to gradually develop in the systemic circulation.
The stage of pronounced stagnation in both circles of blood circulation, or the fourth stage. At this stage, atrial fibrillation begins to appear.
The stage of decompensation (dystrophy), or the fifth stage. Heart failure reaches its most severe degree.

Causes

As already mentioned, the etiology of mitral stenosis is almost always associated with acquired diseases and conditions. Congenital forms of stenosis are extremely rare. In most cases (up to 85%), the causes of the disease are due to rheumatism - acute rheumatic fever. Against its background, rheumatic heart disease develops, or inflammatory process in the muscle and connective tissue of the heart. Rheumatism can be a complication of angina, which is caused by group A hemolytic streptococcus, and complications of angina usually occur after 2-3 weeks. With rheumatism, the valve leaflets become thick, their movements are limited, they coalesce, and the mitral opening decreases in size.

Other causes that can provoke mitral valve stenosis are:

CHD (congenital heart defects). Sometimes, against the background of other defects, mitral stenosis occurs with age.
Atherosclerosis is the formation of fatty plaques in the coronary vessels and in the heart.
Calcification is the appearance of calcium deposits on the valve leaflets, which in one way or another provokes a narrowing of the inlet.
Thrombosis of the heart chambers - a blood clot that appears can narrow the atrioventricular orifice.
Syphilis - this pathology in the advanced stage is also capable of provoking the appearance of adhesions and scars on the mitral valve.
Heart injury - in the rarest cases, after a car accident, a blow to the chest area, scars begin to form on the valve.
Irradiation, radiation - these factors can also lead to the appearance of adhesions and scars on the valve.
Infective endocarditis - bacteria or viruses can provoke inflammation of the heart tissue and the appearance of valvular defects.
Tumors or metastases - oncological processes can block the mitral opening, leading to its stenosis.

Since in recent years rheumatism has become much less diagnosed than before, mitral valve stenosis is also observed in fewer cases. However, all the diseases mentioned above remain risk factors, as well as getting radiotherapy and reportedly taking wormwood preparations and migraine medications.

Symptoms of mitral valve stenosis

As a rule, the disease progresses over the years, so a person may not be aware of the existing problem for a long time. Since the first symptom is a decrease in exercise tolerance, the patient can simply gradually refuse them, continuing to continue not to devote time to health. In many people, the initial clinical signs appear during pregnancy, stress, other overloads of the body, or already with the development of complications, in particular, atrial fibrillation. Often the very first sign is an episode of thromboembolism, more often a stroke, or an episode of ventricular fibrillation.

Perhaps the absence of such complications for a long time and the progression of heart failure. Then the symptoms of the disease are as follows:

shortness of breath on exertion, then at rest;
bouts of nocturnal shortness of breath;
increased fatigue, fatigue;
orthopnea;
cough;
hemoptysis;
transient hoarseness of voice;
interruptions in the heartbeat;
pain in the chest by the type of angina pectoris;
pale skin;
bluish-pink blush on the cheeks;
pulsation in the epigastrium;
heaviness in the abdomen;
enlargement and soreness of the liver;
ascites;
leg swelling.

If the disease is provoked by rheumatism, but similar signs appear 15-30 years after its transfer, but possibly more fast development events.

Complications and their prevention

The smaller the remaining area of the mitral orifice, the more pronounced the symptoms, the worse the person tolerates any load and the higher the likelihood of an early development of complications. Only chance prevent them - start early conservative therapy, which in the initial stages of the disease copes well with the resulting hemodynamic disorders and prevents them from progressing.

The most common complications occur in the lungs. These include cardiac asthma, bronchitis, bronchopneumonia, lobar pneumonia and pulmonary edema, pneumothorax, and all stem from existing pulmonary hypertension and pulmonary congestion. There is also a high probability of developing extrasystoles, paroxysms of tachycardia, atrial fibrillation, atrial flutter. If the patient already has atrial fibrillation, this is recognized critical period during mitral stenosis, as it will progress faster further.

Often, in severe stages of mitral valve stenosis, recurrent PE occurs with lung infarction. Blood clots from the left atrium can penetrate the brain and provoke a stroke, as well as affect the kidneys, spleen, and legs. With atrial fibrillation, the risk of thromboembolism is higher than ever, especially in the elderly. The patient may die from acute heart failure, ventricular fibrillation. In general, without treatment, hemodynamic disorders inevitably lead to complications and death from mitral valve stenosis.

Diagnosis of pathology

When examining a patient and conducting physical examinations, the doctor can identify such deviations:

abnormal heart sounds and murmurs (particularly diastolic murmur);
increased heart murmur during exercise;
pulsation of the heart at the left edge of the sternum;
swelling of the jugular veins;
diastolic trembling in the position on the left side;
bluish tint of the cheeks in the cheekbones;
an increase in the abdomen;
swelling of the legs (often the legs and feet).

If the patient has active rheumatism, then this will be reflected in blood tests (increased white blood cells, clotting disorders, specific indicators). In the analysis of urine, protein and white blood cells often appear, as well as other signs of impaired kidney function. But instrumental studies are more important for detecting mitral stenosis:

ECG. Changes are recorded that reflect hypertrophy of the myocardium of the left ventricle and atrium, as well as various heart rhythm disturbances. In the absence of the necessary data on a standard 12-lead ECG, the Holter monitoring method is used.
Chest X-ray. Reveals stagnation in the lungs, changes in the cardiac configuration, expansion of the shadow of the heart.
Ultrasound of the heart. It allows not only to identify all the ongoing changes related to the valve, but also to measure the pressure and blood flow velocity, the size of the heart chambers, the degree of myocardial hypertrophy, other valvular defects and organic changes.
Cardiac catheterization. It may be indicated before surgery in case of unclear diagnosis and to more accurately measure the pressure difference in the left chambers of the heart.

Conservative and surgical treatment

The type of treatment is selected for each patient individually based on the stage of the disease and the rate of its progression, as well as the existing complications. So, with full compensation of the defect and a small degree of narrowing of the mitral orifice, medications can prevent blood stasis, and the operation is not indicated. The second and third stages (stages of defect subcompensation) are already indications for an operation, as well as for the constant use of drugs. Due to the high risk severe complications in the decompensated stage of mitral stenosis, surgical treatment is no longer done. The terminal stage allows only palliative treatment in order to alleviate the suffering of a person.

In general, the drugs that are used to treat mitral stenosis are as follows:

Cardiac glycosides for the treatment of atrial fibrillation and increased ventricular contractility (Korglikon, Digitoxin).
Diuretics to reduce edema and reduce stagnation in the pulmonary circulation (Veroshpiron, Lasix).
Nitrates for expansion peripheral vessels and reducing pain, shortness of breath and other symptoms (Nitroglycerin, Kardiket).
ACE inhibitors and angiotensin receptor blockers for a cardioprotective effect and prevention of myocardial cell destruction (Valz, Ramipril).
Beta-blockers to slow down the rhythm and prevent severe forms arrhythmias (Nebilet, Bisoprolol).
Anticoagulants for the prevention of thrombosis (Heparin, Warfarin).
Antibiotics, glucocorticosteroids, NSAIDs for rheumatism, if any, or for repeated rheumatic attacks.

Operations are indicated for 2-3 (sometimes 4) stages of mitral valve stenosis.

Contraindications, except for the severe stage of the disease, are acute infections, somatic diseases in the stage of decompensation, acute heart disease. Valvuloplasty is performed in the absence of calcification, severe deformation of the valves, damage to the papillary muscles, chords. The most commonly performed balloon valvuloplasty is the introduction of a catheter with a balloon into the mitral orifice and expansion of the latter by inflating the balloon. In the presence of valve insufficiency and blood clots in the heart, the operation is not performed.

If this intervention is prohibited or ineffective, there are other types of operations. Open valvuloplasty involves cutting the fused foramen through an incision in the sternum. Closed or open commissurotomy involves the removal of calcifications, blood clots, adhesions, after which plastic valve and mitral orifice are performed. When the patient has a gross deformation of the valve apparatus, an extreme measure is used - mitral valve replacement. Artificial prostheses carry a high risk of blood clots, so a person will have to take anticoagulants for the rest of his life. Biological valves are not dangerous in this regard, but require regular replacement due to their short service life.

Folk methods and lifestyle

Not a single folk remedy will help solve the problem - save a person from mitral valve stenosis. Therefore, if desired, you can drink only general strengthening preparations and decoctions, which have a positive effect on the myocardium and blood vessels. Much more important to practice proper nutrition- do not abuse salt, fats, smoked meats. It is advisable to control the amount of fluid consumed in order to prevent edema, walk more often, and avoid stress.

What Not to Do

With mitral stenosis, it is impossible to carry out types of work that are associated with physical work or involve great emotional stress. It is strictly forbidden to supercool, exercise active species sports. When carrying out abdominal operations, any gynecological and dental procedures, one should not forget about the advance use of antibiotics. Pregnancy is strictly forbidden to plan with a stenosis of more than 1.6 cm2. and in the presence of symptoms of the disease, because otherwise it is shown to be interrupted for health reasons.

Prevention and prognosis

Without the right treatment the long-term prognosis is unfavorable - 7-10 years can pass between the onset of symptoms and the setting of severe disability. Approximately 80% of people live 10 years or more, but in the absence of a decompensation stage. If the pathology has already gone so far, then the 10-year survival rate drops to 10%. With the development of pulmonary hypertension, the life span is not more than 3 years. Modern views operations without valve replacement can cure up to 95% of people, but some need a second intervention.

For the prevention of the disease, the following measures are important:

early treatment of rheumatism;
sanitation of foci of chronic infection;
observation by a cardiologist when entering a risk group;
in the presence of mitral stenosis, secondary prevention of episodes of rheumatic fever is important by continuous administration of penicillin once a month at an age dosage.

mitral stenosis- narrowing of the left atrioventricular orifice due to fusion of the leaflets bicuspid valve, changes in subvalvular structures and fibrous degeneration of the valve ring. This creates obstacles to the flow of blood from the left atrium and is accompanied by a decrease in stroke volume and cardiac output. Mitral stenosis leads to pulmonary hypertension syndrome. The most common cause of mitral stenosis is rheumatic fever.

Mitral stenosis classification

Most wide use in Russia received the classification of mitral stenosis proposed by A.N. Bakulev and E.A. Damir.

It includes 5 stages of development of the defect:

I - stage of complete compensation of blood circulation. The patient does not present any complaints, but objective examination signs characteristic of mitral stenosis are found. The area of the mitral orifice is 3-4 cm2, the size of the left atrium is no more than 4 cm.

II - stage of relative circulatory insufficiency. The patient complains of shortness of breath that occurs during physical exertion, there are signs of hypertension in the pulmonary circulation, venous pressure is slightly increased, but there are no pronounced signs of circulatory failure. The area of the mitral orifice is about 2 cm2. The size of the left atrium is from 4 to 5 cm.

III - the initial stage of severe circulatory failure. At this stage, there are phenomena of stagnation in the small and large circles of blood circulation. The heart is enlarged. Venous pressure is significantly increased. There is an enlargement of the liver. The area of the mitral orifice is 1-1.5 cm2. The size of the left atrium is 5 cm or more.

IV - stage of pronounced circulatory failure with significant stagnation in the large circle. The heart is greatly enlarged, the liver large sizes, dense. High venous pressure. Sometimes small ascites and peripheral hypostases. Patients with atrial fibrillation also belong to this stage. Therapeutic treatment gives an improvement. The mitral orifice is less than 1 cm2, the size of the left atrium is more than 5 cm.

V - corresponds to the terminal dystrophic stage of circulatory failure according to V.Kh. Vasilenko and N.D. Strazhesko. There is a significant increase in the size of the heart, a large liver, a sharply increased venous pressure, ascites, significant peripheral edema, constant shortness of breath, even at rest. Therapeutic treatment does not work. The area of the mitral orifice is less than 1 cm2, the size of the left atrium is more than 5 cm.

clinical picture.

The main complaint of patients with mitral stenosis is shortness of breath as a result of a decrease in the minute volume of blood circulation and a violation of the mechanism external respiration. Its intensity is directly dependent on the degree of narrowing of the mitral orifice.

Palpitations are the second sign of mitral stenosis after shortness of breath and represent a manifestation of a compensatory mechanism in conditions of insufficient minute volume of blood circulation.

Hemoptysis and pulmonary edema are less common and occur mainly when rheumatic vasculitis is combined with severe congestion in the pulmonary veins and bronchial vessels. Rarely, hemoptysis is associated with pulmonary infarction.

Pulmonary edema is caused by severe hypertension of the small circle in combination with left ventricular failure. The resulting hypoxia leads to an increase in the permeability vascular wall and penetration of the liquid fraction of blood into the alveoli.

Cough - frequent sign mitral stenosis and is usually associated with congestive bronchitis.

Pain in the region of the heart is a less constant sign of this defect, they appear only with a significant increase in the left atrium, accompanied by compression of the left coronary artery.

General physical weakness is very characteristic of mitral stenosis and is a consequence chronic hypoxia body, especially the skeletal muscles. The clinical manifestations of mitral stenosis are very diverse. It can be masked by violations intracardiac hemodynamics from other causes, may not cause subjective sensations at all and at the same time cause a sudden attack of acute heart failure with a fatal outcome.

Diagnostics.

In typical cases, there is pallor of the skin with cyanosis of the lips, cheeks, and tip of the nose.

Auscultatory data are very characteristic: "flapping", "cannon" first tone, accent and bifurcation of the second tone over the pulmonary artery.

The second component of this tone is recorded as a "click".

Diastolic murmur with presystolic enhancement over the apex of the heart is a characteristic auscultatory sign of mitral stenosis if sinus rhythm persists.

With tachycardia, the listed auscultatory signs may be absent. Therefore, when examining a patient, it is necessary to achieve a decrease in heart rate (calm down, give the patient a horizontal position, possibly resort to medication), and then repeat auscultation and phonocardiography.

X-ray signs are quite characteristic: a heart of a mitral configuration with a sharp expansion of the pulmonary artery and left atrial appendage, pronounced congestion in the vessels of the lungs of a mixed nature, in severe cases, signs of hemosiderosis. On the radiograph in the right lateral projection, an increase in the right ventricle with filling of the retrosternal space is seen.

The contrasted esophagus in this projection deviates along an arc of small radius (up to 6 cm), which indicates an increase in the left atrium. A characteristic electrocardiographic sign is the deviation of the electrical axis of the heart to the right, signs of hypertrophy of the right ventricle and left atrium, as well as atrial fibrillation in more later stages diseases.

Phonocardiographic signs, as a rule, correspond to other auscultations. Echocardiographic data are very characteristic, allowing with great accuracy to measure the mitral orifice, to get an idea of the nature anatomical changes valve (Fig. 2, a, b), to recognize the presence of left atrial thrombosis and evaluate the function of the heart.

Treatment.

The main method of treatment of patients with mitral stenosis is surgical.

Surgical treatment is indicated for patients with stage II-IV disease. Patients with stage I do not need surgery. In patients with stage V mitral stenosis, surgical treatment is absolutely contraindicated, since it is associated with a very high risk.

With mitral stenosis, it is possible to perform both closed (i.e. without the use of cardiopulmonary bypass) and open (in conditions of cardiopulmonary bypass) surgical interventions. The last group includes valve-preserving interventions (open mitral commissurotomy), as well as valve replacement with an artificial prosthesis. In uncomplicated mitral stenosis, it is possible to perform a closed mitral commissurotomy.

Closed mitral commissurectomy

The operation consists in digital or instrumental expansion of the mitral orifice by separating the adhesions of the mitral valve in the area of commissures with subvalvular structures. Closed mitral commissurotomy can be performed from a left or right access to the heart, however, at present, it is mainly performed from a right anterolateral thoracotomy. This access provides, if necessary, the possibility of transition to the correction of the defect under cardiopulmonary bypass. When performing an intervention from a right-sided access to the heart, a finger and an instrument are introduced to the mitral valve through the interatrial sulcus (Fig. 3, a, b). In cases of a thrombus in the left atrium, extensive calcification of the mitral valve, ineffectiveness of attempts at closed commissurotomy, as well as in the event of severe valve insufficiency (grade II or more), after separation of commissures or damage to valvular structures, they proceed to open correction of the defect under conditions of cardiopulmonary bypass.

Open mitral commissurotomy

Performing an open mitral commissurotomy consists in dissecting the commissures and subvalvular adhesions of the stenotic mitral valve under visual control under cardiopulmonary bypass (Fig. 4).

If it is impossible to save the valve (with severe subvalvular adhesions, massive calcification, signs of active infective endocarditis), as well as in case of mitral valve insufficiency after previous commissurotomies, its prosthesis is performed (Fig. 5) using artificial or biological prostheses (Fig. 6) .

One of the possible methods for correcting mitral stenosis in its uncomplicated course is percutaneous balloon dilatation. The essence of the method is to carry out a special balloon under X-ray and ultrasound control into the opening of the mitral valve and expand it by means of a sharp inflation of the balloon, as a result of which the valve leaflets are separated and the stenosis is eliminated. Instrumentation to the mitral valve can be delivered using two approaches: antegrade (from femoral vein through the interatrial septum into the left atrium) or retrograde (from the femoral artery to the left ventricle).

One of serious illnesses heart is mitral stenosis. It is characterized by a narrowing of the opening connecting the left ventricle and the corresponding atrium, between which there is a special mitral valve. If its lumen decreases, then this becomes the reason that the passage of blood is difficult.

Disease prevalence

Most often, mitral valve stenosis is diagnosed in people of pre-retirement age. It affects 40-60-year-old patients, among whom women are much more common. True, the disease can hardly be called common, no more than 0.08% of people suffer from it.

True, if you have been diagnosed with acquired heart disease, then there is a 90% chance that the mitral valve will be affected. People suffering from rheumatism have a 75% chance of developing heart muscle lesions.

Description of the disease

Mitral stenosis and mitral insufficiency develop with fibrotic valve changes. They are accompanied by the fusion of commissures, calcification of the valves and their thickening. In addition, there may be a shortening of the tendon parts of the chords, their fusion. The mitral valve becomes funnel-shaped. A feature of the disease is that the passage does not close completely. Blood, passing into the ventricle, partially returns to the left atrium. This process is called regurgitation.

If in normal condition the hole area can be about 4-6 cm 2, then in a critical position it can decrease to 0.5 cm 2. At the same time, pressure in the left atrium increases, which causes its hyperfunctioning. Following this, the pressure in the pulmonary veins increases, a spasm of arterioles begins in the pulmonary circulation. All this leads to deterioration of the work of the right ventricle, congestion in the veins, supraventricular tachyarrhythmias.

Causes of problems

In order to pay attention to the disease in time, it is necessary to know the signs of mitral stenosis. But it is also important to understand what exactly can lead to the development of the disease.

The most common cause is rheumatic diseases. By the way, they can even develop as a complication of a sore throat caused by a streptococcal infection in the throat. In 75% of cases, rheumatism leads to these lesions. If it was this disease that caused stenosis, then its manifestations develop quite quickly. This is due to the constant traumatic influence high blood pressure blood to the valve.

Also, the disease can be a congenital pathology. In this case, it is enough early age mitral valve stenosis is diagnosed. Treatment with medication in such situations, as a rule, is not applied. With a congenital form of the disease, the only way to get rid of the problem is with the help of surgical intervention.

Among the rather rare causes, ionizing radiation or the intake of certain medications, for example, preparations containing wormwood, are also called.

In addition, mitral stenosis can be provoked by calcium growths, tumors or blood clots.

Classification of disease types

Doctors distinguish five stages of the disease. If at first the disease is practically not manifested in any way, then with development it can cause death.

The first stage is also called compensatory. There are no symptoms of the disease, patients can even perform significant physical activity without suspecting problems. They are usually discovered during routine checkups.

With subcompensatory or second degree mitral stenosis, symptoms begin to appear during exercise. The lumen of the valve narrows significantly, increasing the load on the right ventricle. The stage is characterized by an increase in the blood pressure gradient in the left atrium. This becomes necessary in order to maintain cardiac output at the same level.

In the third stage, there are congestion in the circulatory system. An increase in the heart muscle and liver is also diagnosed. This significantly increases venous pressure.

Severe circulatory failure appears in the fourth stage. It also shows serious stagnation, a significant increase in the liver and compaction of its structure, peripheral edema, ascites appear.

At the fifth degree begin irreversible changes in the internal organs. The disease leads to the appearance of edema, shortness of breath even at rest, cardiomegaly, cirrhosis of the liver.

The shape of the stenosis may look like a fish mouth - it has a funnel shape. It can also resemble a jacket loop or be characterized by a double narrowing.

Depending on the size of the lumen, sharp (less than 0.5 cm 2), pronounced (0.5-1 cm 2) and moderate (up to 1.5 cm 2) stenosis are distinguished.

Symptoms of the disease

If mitral stenosis has just begun to develop, then it will not work to find out about it without a special examination. True, deterioration can occur suddenly. Interruptions in the work of the heart, a sudden increase in the frequency of contractions, the appearance of causeless shortness of breath can suggest the development of the disease. All this suggests that you may develop mitral stenosis. Symptoms indicate that tissue circular hypoxia has begun. This state very often accompanies the specified defect.

In the initial stages, these signs appear after significant physical activity. But over time, they begin to appear in a state of complete rest.

Another symptom of the disease is a cough. This is how it manifests chronic form congestive bronchitis. In some cases, hemoptysis may even occur.

The clinical picture includes pain in the region of the heart, weakness, fatigue, and even some hoarseness. These are all indications that you may have mitral stenosis. Symptoms also include cyanosis of the lips, pallor of the nasolabial triangle and other skin, flushing of the cheeks, tachycardia, chest deformity (the so-called heart hump), swelling of the veins of the neck.

One of the main symptoms is also cardiac asthma. It is expressed in sudden attacks of suffocation. They occur due to a malfunction of the left ventricle.

Disease Definition

In addition to the above symptoms, there are a number of signs that the doctor is guided by to install accurate diagnosis. But for this you need to visit a cardiologist. Only he can accurately determine mitral stenosis. Noise in the heart, by the way, is one of the signs of this disease. But in addition to it, congestion in the lungs, arrhythmia, thrombosis, and pulmonary hypertension testify to the disease.

There are several signs by which the doctor may suspect the development of the disease. Physicians check for the following symptoms left atrial enlargement:

Popova: on the arteries of the left hand, there is a reduced filling of the pulse.

Nesterov: with the help of palpation, alternating shocks of the left atrium and the corresponding ventricle can be determined.

Cassio: the first tone after the apical impulse is late.

Botkin I: left half the chest is visually reduced.

Botkin II: on the left side of the sternum there are wheezing and crepitus.

Auenbrugger: there is an epigastric pulsation in the left ventricle.

In addition to these, it also checks for valvular symptoms and signs of disease caused by a violation of the pumping function of the heart muscle. This is evidenced by the so-called "quail rhythm", the presence of low-frequency diastolic noise, wet rales, which can be heard in the basal regions. Also, problems are indicated by the expansion of the borders of the heart to the right side.

To confirm the suspicions, the cardiologist may recommend a hardware examination, which should confirm the diagnosis of mitral stenosis. Auscultation, which allows you to identify the most significant signs, is a reliable diagnostic method. Therefore, do not underestimate the words of a doctor who says that you have a chance of developing stenosis.

Research methods

In order to accurately establish the diagnosis and determine the degree of narrowing of the lumen of the mitral orifice, you can use a variety of diagnostic methods.

Electrocardiography in the initial stages is often not changed. But with mitral valve insufficiency, there is a deviation of the electrical axis to the left. Other indicators also change. The expressed stenosis is characterized by a deviation of an axis to the right. Also, with it, signs of hypertrophy of both atria and the right ventricle are observed. Common symptom is the appearance of atrial extrasystoles, and in more advanced cases - atrial fibrillation.

Echocardiography makes it possible not only to determine the stenosis of the mitral orifice, but also to accurately assess the dimensions of the walls and cavities of the left atrium and ventricle. With this examination, you can assess the condition in which the mitral valve is located. Doppler allows you to see the abnormal movement of blood towards the left atrium from the corresponding ventricle. Echocardiography is one of the most informative methods examinations. With its help, various heart defects are diagnosed.

X-ray examination reveals the rounding of the 4th arch in the anteroposterior projection, which is observed due to hypertrophic phenomena in the left ventricle. Also, the images show bulging of the 3rd arch. It occurs as a result of an increase in the left atrium. This is especially well seen in the left lateral projection, in this position this section displaces the esophagus along an arc of a larger radius, which can be visualized by the contrast agent present in it. Mitral stenosis is also characterized by a change in the shape of the heart muscle. In this case, the pulmonary trunk can be expanded more than the aorta.

Possible Complications

If you have been diagnosed with mitral stenosis, then you cannot let the disease take its course. This is fraught with the development of a number of problems.

For example, in severe stages of the disease, heart failure develops. Wherein pathological condition the blood in the body is pumped too weakly.

Another complication can be atrial fibrillation. The expansion of the left side leads to the fact that arrhythmia begins. As a result, contractions of the left atrium occur in a chaotic manner.

Also, the disease leads to stagnation of blood in the lungs. Their edema begins, while the plasma collects in the alveoli. This is all accompanied by a cough, in some cases even hemoptysis.

Thrombi begin to form in the atrial cavity due to stenosis in some cases. They can be carried throughout the body with the bloodstream, leading to serious problems.

Mitral stenosis also leads to the expansion of the cavity of the heart. This is due to the fact that the hole narrows, the left atrium is constantly overflowing with blood. In the process of the development of the disease, the size of the right side of the heart subsequently increases.

More often associated problems begin to develop in the third stage of the disease.

Medical treatment

If the disease was detected at a stage when clinical signs are not yet expressed, then therapy is aimed at ensuring that hemodynamics does not change with mitral stenosis. To do this, doctors recommend slightly limiting physical activity and adjusting eating habits. So, it is necessary, if possible, to abandon the use of salt and foods that lead to fluid retention in the body.

When symptoms appear, treatment is aimed at reducing heart failure, getting rid of arrhythmias, and preventing thrombosis. Also, therapy is aimed at preventing the development of infective endocarditis, which often develops as a result of bacteria entering the body.

To reduce heart failure, it is necessary to use cardiac glycosides and diuretics. The first of them selectively increase cardiac contractions. These are usually the means plant origin. These can be drugs such as Strofantin, Cymarin, Periplocin, Neriolin. They slow down the heart rate, increasing the strength of each contraction. Diuretics are designed to remove excess salt and water from the body. This reduces the workload on the heart. The doctor may prescribe dichlothiazide or furosemide.

You can prevent thrombus formation with the help of drugs whose action is aimed at thinning the blood. This is necessary if you have mitral valve disease with a predominance of stenosis. Such drugs as "Heparin", "Warfarin", "Omefin", "Sinkumar", "Pelentan" can be prescribed.

Beta-blockers are also prescribed, which can reduce the heart rate and thereby reduce pressure. In addition, antiplatelet agents, such as acetylsalicylic acid, are used in therapy.

Cardiologists advise in some cases to take antibiotics. This is necessary for treatment, extraction of teeth or other interventions in which there is a risk of bacteria entering the body. The fact is that the affected mitral valve is more susceptible to possible infections.

Surgery

Not in all cases, with medications it is possible to restore the condition of a patient diagnosed with mitral stenosis. Treatment in some cases will not give the desired effect.

As a rule, starting from the third stage of the disease, cardiologists recommend not to refuse surgical treatment. It can be done using traditional or minimally invasive methods. The latter is, of course, preferable. They are less traumatic and better tolerated.

TO traditional methods referred to as valvuloplasty. This method requires an open incision in the region of the heart. During the operation, the surgeon cuts the fused leaflets. But in the future they can connect again, and the operation will have to be repeated.

Most effective method is a valve replacement. For this procedure, neither hemodynamics in mitral stenosis, nor the severity of the disease is important. It can be carried out even under running conditions. Mechanical or biological valves can be used as replacements. True, the use of the former is fraught with the risks of developing thrombosis. And the second have a limited lifespan.

Valvotomy

Balloon valvuloplasty aims to repair the mitral valve without direct heart surgery. It's running in the following way. The surgeon inserts a thin catheter into the femoral artery. It has a special canister at the end. The catheter is passed through the artery to the mitral valve. When it is in place, the balloon inflates and due to this, the fused valve leaflets diverge. After that, it is deflated and removed from the cavity of the heart.

The procedure takes place under x-ray control. But for its implementation there are a number of contraindications. So, if mitral valve stenosis is combined with its insufficiency or there are blood clots in the heart cavity, then valvotomy cannot be performed. There is also a risk of complications. As a result of such intervention, the valve may change its shape. Because of this, it may stop closing the hole. It is also impossible to exclude the development of embolism of the pulmonary artery or cerebral vessels by thrombi or fragments of valve tissue.

In most cases, re-intervention is required after about 10 years.