Therapy of the disease requires an integrated approach. At the asymptomatic stage, drug treatment is not required. At the initial stages, conservative therapy with diuretics and beta-blockers is used. General strengthening therapy, vitamins are prescribed.
Surgical treatment of mitral stenosis involves closed dissection of the valve cusps using special tools or the expansion of the mitral orifice, with constant monitoring of blood circulation by hardware. If necessary, valve plastic surgery and prosthetics are performed.
Indications for surgical intervention are a narrowing of the valve area of more than 1 cmXNUMX, thrombosis, high blood pressure, severe disturbances in the rhythm and activity of the heart, and pathology in the lungs.
The treatment of mitral defect is divided into conservative and surgical. These two methods are used in parallel, because before the operation and after it, the medical support of the patient is especially important.
Drug therapy includes the appointment of the following groups of drugs:
- Beta-blockers are drugs that reduce the load on the heart due to a reduction in heart rate and a decrease in vascular resistance, especially when blood stagnates in the vessels. More often, concor, coronal, egilok, etc.
- ACE inhibitors – “protect” blood vessels, heart, brain and kidneys from the negative effects of increased vascular resistance. Apply perindopril, lisinopril, etc.
- ARA II blockers – lower blood pressure, which is important for patients with stenosis who have concomitant hypertension. More often used losartan (lorista, lozap) and valsartan (valz).
- Drugs that have antiplatelet and anticoagulant effects – prevent increased blood clots in the bloodstream, are used in patients with angina pectoris, a history of heart attack, as well as with atrial fibrillation. Prescribe aspirin Cardio, acecardol, thromboass, warfarin, clopidogrel, xarelto and many others.
- Diuretic drugs are one of the most important groups in the presence of chronic heart failure, as they prevent fluid retention in arteries and veins, and reduce afterload on the heart. The use of indapamide, veroshpiron, diuvere, etc. is justified.
- Cardiac glycosides – shown with a decrease in contractile function of the left ventricle, as well as in individuals with constant atrial fibrillation. Digoxin is mainly prescribed.
Contraindications for percutaneous mitral commissurotomy:
- the area of the mitral foramen is greater than 1,5 cm2;
- left atrial thrombus;
- moderate and severe mitral regurgitation;
- severe or bicomissural calcification;
- severe concomitant lesion of the aortic valve or severe combined stenosis and tricuspid valve insufficiency;
- concomitant coronary artery disease requiring coronary artery bypass grafting.
Surgical treatments for mitral stenosis:
- Transthoracic commissurotomy: a dilator is inserted through the top of the left ventricle into the left AV hole; adhesion rupture occurs. It gives very good results; cardiopulmonary bypass is not required.
- Open commissurotomy (1)
It is performed in a cardiopulmonary bypass. During the operation, the commissures are dissected, the brazed chords and papillary muscles are disconnected, thrombi are removed from the left atrium, the valves are free of calcifications, and the ear of the left atrium is removed.
With mitral insufficiency, mitral annuloplasty is performed.
Open commissurotomy (2)
This operation is more preferable than balloon valvuloplasty in the following cases: with mild and moderate mitral insufficiency, severe calcification and low valve mobility (especially with lesions of the valvular apparatus);
With left atrial thrombosis, infectious endocarditis (transferred or current), damage to other valves, severe coronary heart disease and with failed balloon valvuloplasty.
It is the operation of choice at a young age with a slight deformation and preserved mobility of the valves (there is no significant thickening and calcification of the valves, pronounced lesions of the chords and papillary muscles).
In some cases, valvuloplasty is effective even with a sufficiently significant deformation and reduced leaflet mobility. Balloon valvuloplasty is indicated in inoperable cases or if the operation itself or the presence of a prosthesis is undesirable (in old age, with concomitant serious illnesses, pregnancy).
Mitral valve replacement
Mitral valve prosthetics (or in some cases plastic surgery) is indicated for mitral stenosis, which is complicated by right ventricular failure and severe tricuspid insufficiency requiring tricuspid annuloplasty.
Contraindications to balloon valvuloplasty:
- moderate and severe mitral regurgitation;
- left atrial thrombosis (thrombosis may disappear after 2-3 months of treatment with anticoagulants);
- coronary heart disease requiring coronary artery bypass grafting;
- severe damage to several valves.
Conservative drug therapy for this defect is of secondary importance. Its main purpose:
- Treatment of diseases that provoked pathology (autoimmune, infectious).
- Neutralization of disease symptoms when surgical intervention is not possible or in the preoperative period. For this purpose, diuretics (Furosemide, Veroshpiron), cardiac glycosides (Digoxin, Celanide), adrenergic blockers (Atenolol), anticoagulants (Warfarin, Heparin), vitamins and minerals are prescribed.
Drug therapy, along with dieting and minimizing physical activity, is the leading method of treating patients with the disease in the stage of compensation.
Conservative therapy is carried out:
- In the compensation stage.
- With a satisfactory general condition of the patient.
- With a slight degree of narrowing of the valve.
- Diuretics – with the development of cough and hemoptysis (veroshpiron).
- Cardioprotectors – trimetazidine, riboxin.
- Anticoagulants – with the threat of thrombosis (atrial fibrillation): heparin, warfarin.
- In patients without arrhythmia with mitral stenosis, beta-blockers (bisoprolol, metaprolol), calcium channel blockers (nifedipine) are used.
- In patients with arrhythmia, antiarrhythmics (amiodarone) are used.
- Bronchodilators (ipratropium bromide).
- Mucolytics (expectorants – mucaltin).
But more often, patients go to the doctor when the symptoms of the disease are already very pronounced – in this case, surgery is a classic treatment. Also, the operation is performed in those situations where drug treatment cannot compensate for heart disease in the form of mitral stenosis, and indications for surgical treatment are as follows:
- Pressure in the pulmonary artery over 60 mmHg
- Left atrial thrombosis.
- Narrowing the valve to 1 sq.cm.
- Decompensation of a defect (heart failure).
In this case, the following types of operations can be carried out:
Balloon valvuloplasty is a minimally invasive operation using coronary artery bypass grafting under the control of x-rays and ultrasound. It is carried out with uncomplicated mitral stenosis 2-3 degrees.
In the case of a stage of severe decompensation of pathology (grade 4-5), any corrective surgery is contraindicated, and only palliative medication is prescribed to patients.
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Mitral valve stenosis: how is it manifested, can it be cured
Mitral valve stenosis is a heart defect that is caused by thickening and immobility of the mitral valve cusps and narrowing of the atrioventricular opening due to the fusion of the sections between the cusps (commissures). Many have heard about this pathology, but not all cardiologist patients know why the disease occurs and how it manifests, and many are interested in whether mitral valve stenosis can be completely cured. We’ll talk about this.
In 80% of cases, mitral valve stenosis is provoked by previous rheumatism. In other cases, mitral valve damage can be caused by:
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- other infectious endocarditis;
- heart injuries;
- systemic lupus erythematosus;
- hereditary causes;
- atrial myxoma;
- malignant carcinoid syndrome.
The mitral valve is located between the left atrium and the left ventricle. It has a funnel shape and consists of valves with chords, the fibrous ring and papillary muscles, which are functionally connected with the left atrium and ventricle.
With its narrowing, which in most cases is caused by rheumatic lesions of the heart tissue, the load on the left atrium increases. This leads to an increase in pressure in it, its expansion and causes the development of secondary pulmonary hypertension, which leads to right ventricular failure.
In the future, such a pathology can provoke thromboembolism and atrial fibrillation.
With the development of mitral valve stenosis, the following stages are observed:
- Stage I: heart disease is completely compensated, the atrioventricular opening is narrowed to 3-4 square meters. see, the size of the left atrium does not exceed 4 cm;
- Stage II: hypertension begins to appear in the pulmonary circulation, venous pressure rises, but there are no pronounced symptoms of hemodynamic disturbance, the atrioventricular opening is narrowed to 2 square meters. see, the left atrium hypertrophies up to 5 cm;
- Stage III: the patient exhibits severe symptoms of heart failure, the size of the heart increases dramatically, venous pressure rises significantly, the liver increases in size, the atrioventricular opening is narrowed to 1,5 square meters. cm, the left atrium increases in size by more than 5 cm;
- Stage IV: symptoms of heart failure are aggravated, congestion is observed in the pulmonary circulation and the pulmonary circulation, the liver grows in size and becomes denser, the atrioventricular opening is narrowed to 1 square. cm, left atrium increased by more than 5 cm;
- Stage V: characterized by the terminal stage of heart failure, the atrioventricular opening is almost completely obstructed (closes), the left atrium increases in size by more than 5 cm.
In the degree of change in the structure of the mitral valve, three main stages are distinguished:
- I: calcium salts settle on the edges of the valve flaps or are located focal in the commissures;
- II: calcium salts cover all valves, but do not extend to the fibrous ring;
- III: calcification affects the fibrous ring and nearby structures.
Mitral valve stenosis can be asymptomatic for a long time. From the moment of the first infectious attack (after rheumatism, scarlet fever or sore throat) until the first characteristic complaints of a patient living in a temperate climate appear, about 20 years can pass, and from the moment of severe dyspnea (at rest) until the patient dies, about 5 years pass. In hot countries, this heart disease progresses faster.
With mild mitral valve stenosis, complaints are not presented to patients, but when they are examined, many signs of malfunctioning of the mitral valve can be detected (increased venous pressure, narrowing of the lumen between the left atrium and ventricle, an increase in the size of the left atrium).
A sharp rise in venous pressure, which can be caused by various predisposing factors (physical exertion, sexual intercourse, pregnancy, thyrotoxicosis, fever and other conditions), manifests itself as shortness of breath and cough.
Subsequently, with the progression of mitral stenosis, the patient’s physical endurance sharply decreases, they subconsciously try to limit their activity, episodes of cardiac asthma, tachycardia, arrhythmias (extrasystole, atrial fibrillation, atrial flutter, etc.) appear and lung edema can develop.
The development of hypoxic encephalopathy leads to dizziness and fainting, which are provoked by physical exertion.
A critical moment in the progression of this disease is the development of a permanent form of atrial fibrillation. The patient has increased shortness of breath and hemoptysis.
Over time, signs of stagnation in the lungs become less pronounced and easier, but constantly increasing pulmonary hypertension leads to the development of right ventricular failure.
The patient has complaints of edema, severe weakness, heaviness in the right hypochondrium, cardialgia (in 10% of patients), and signs of ascites and hydrothorax (often right-sided) can be detected.
When examining the patient, cyanosis of the lips and a characteristic raspberry-cyanotic blush on the cheeks (mitral butterfly) are determined. During percussion of the heart, a shift of the borders of the heart to the left is detected.
When listening to heart sounds, the amplification of I tone (clapping tone) and additional III tone (“quail rhythm”) are determined.
Such patients often have diseases of the respiratory system (bronchitis, bronchopneumonia and croupous pneumonia), and the detachment of blood clots that form in the left atrium can lead to thromboembolism of the vessels of the brain, limbs, kidneys or spleen. When the thrombi overlap the lumen of the mitral valve, patients experience sharp chest pain and fainting.
Mitral valve stenosis can also be complicated by relapses of rheumatism and infectious endocarditis. Repeated episodes of pulmonary embolism often end in the development of pulmonary infarction and lead to the death of the patient.
A characteristic feature of mitral stenosis is atrial fibrillation, detected on an ECG.
A preliminary diagnosis of mitral valve stenosis can be established clinically (i.e., after analyzing complaints and examining the patient) and conducting an ECG, which shows signs of an increase in the size of the left atrium and right ventricle.
To confirm the diagnosis, the patient is assigned a two-dimensional and Doppler echocardiography, which allows us to establish the degree of narrowing and calcification of the mitral valve cusps, the size of the left atrium, the volume of chresvalvular regurgitation and pressure in the pulmonary artery. To exclude the presence of blood clots in the left atrium, transesophageal echocardiography may be recommended. Pathological changes in the lungs are established using radiography.
Patients with no signs of decompensation should be screened annually. The diagnostic complex includes:
When deciding to perform a surgical operation, a patient is prescribed catheterization of the heart and major vessels.
Mitral valve stenosis can only be eliminated surgically, because taking medications cannot eliminate the narrowing of the atrioventricular opening.
The asymptomatic course of this heart disease does not require the appointment of drug therapy. When symptoms of mitral valve stenosis appear to the patient, in order to prepare for the operation and eliminate the cause of the disease, the following can be prescribed:
- diuretics (in low dosages): hydrochlorothiazide, clopamide, etc .;
- beta blockers: Verapamil, Diltiazem;
- slow calcium tubule blockers: Amlodipine, Normodipine, Amlong.
In the presence of atrial fibrillation and the risk of blood clots in the left atrium, indirect anticoagulants (Warfarin) are recommended, and with the development of thromboembolism, Heparin is prescribed in combination with Aspirin or Clopidogrel (under the control of INR).
Secondary prophylaxis of infectious endocarditis and rheumatism is necessarily carried out for patients with rheumatic mitral stenosis. For this, antibiotics, salicylates and pyrazoline preparations can be used. After this, the patient is recommended a year-round course of taking Bicillin-5 (once a month) for two years.
Patients with mitral stenosis need constant monitoring by a cardiologist, adherence to a healthy lifestyle, and rational employment.
With this disease, pregnancy is not contraindicated in women who have no signs of decompensation and the area of the opening in the mitral valve is at least 1,6 square meters. cm.
In the absence of such indicators, termination of pregnancy may be recommended (in exceptional cases balloon valvuloplasty or mitral commissurotomy may be performed).
With a decrease in the area of the mitral foramen to 1-1,2 square meters. see recurrent thromboembolism or the development of severe pulmonary hypertension, the patient is recommended surgical treatment. The type of surgical intervention is determined individually for each patient:
- percutaneous balloon mitral valvuloplasty;
- open commissurotomy;
- mitral valve replacement.
The results of the treatment of this pathology depend on many factors:
- age of the patient;
- severity of pulmonary hypertension;
- concomitant pathologies;
- degrees of atrial fibrillation.
Surgical treatment (valvulotomy or commissurotomy) with mitral stenosis allows restoration of the normal functioning of the mitral valve in 95% of patients, but in most cases (30% of patients), repeated surgical treatment (mitral recomissurotomy) is required within 10 years.
In the absence of adequate treatment for mitral valve stenosis, the period from the first signs of heart disease to the patient’s disability can be about 7-9 years.
The progression of the disease and the presence of severe pulmonary hypertension and persistent atrial fibrillation increases the likelihood of a fatal outcome. In most cases, the cause of death of patients is severe heart failure, cerebrovascular or pulmonary thromboembolism.
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