Mitral stenosis is an acquired heart disease characterized by a narrowing of the left atrioventricular opening. In clinical cardiology, it is diagnosed in 0,05–0,08% of the population. The narrowing of the mitral orifice can be isolated (40% of cases), combined with mitral valve insufficiency (combined mitral defect) or with damage to other heart valves (mitral-aortic defect, mitral-tricuspid defect). Mitral defect is 2-3 times more often found in women, mainly at the age of 40-60 years.
In 80% of cases, stenosis of the atrioventricular orifice has rheumatic etiology. The rheumatism debut, as a rule, occurs before the age of 20 years, and clinically pronounced mitral stenosis develops after 10-30 years. Among the less common causes leading to mitral stenosis are infectious endocarditis, atherosclerosis, syphilis, and heart injuries.
Rare cases of mitral stenosis of a non-rheumatic nature may be associated with severe calcification of the mitral valve ring and cusps, left atrial myxoma, congenital heart defects (Lutembache syndrome), intracardiac thrombi. Perhaps the development of mitral restenosis after commissurotomy or mitral valve replacement. The development of relative mitral stenosis may be accompanied by aortic insufficiency.
In the vast majority of cases, the cause of mitral stenosis, like other acquired heart defects, is rheumatism (acute rheumatic fever) with the development of rheumatic heart disease – inflammation of the muscle and connective tissue of the heart.
Mitral stenosis lifestyle
For a patient with this disease, it is imperative to observe the following recommendations: eat well and properly, limit the amount of fluid and sodium chloride consumed, establish an adequate mode of work and rest, get enough sleep, limit physical activity and eliminate stressful situations, and stay outdoors for a long time.
A pregnant woman needs to be registered in a antenatal clinic in a timely manner to resolve the issue of prolonging pregnancy and choosing the method of delivery (usually by caesarean section). With compensated defects, pregnancy proceeds normally, but with severe hemodynamic disturbances, pregnancy is contraindicated.
Normally, the area of the mitral foramen is 4-6 square meters. cm, and its narrowing to 2 square meters. cm and less is accompanied by the appearance of intracardiac hemodynamics. Stenosis of the atrioventricular orifice prevents the expulsion of blood from the left atrium to the ventricle. Under these conditions, compensatory mechanisms are activated: the pressure in the atrial cavity rises from 5 to 20-25 mm Hg. Art., there is an elongation of systole of the left atrium, hypertrophy of the myocardium of the left atrium develops, which together facilitates the passage of blood through the stenotic mitral orifice. At first, these mechanisms make it possible to compensate for the effect of mitral stenosis on intracardiac hemodynamics.
However, further progression of the defect and an increase in the transmitral pressure gradient are accompanied by a retrograde increase in pressure in the pulmonary vascular system, leading to the development of pulmonary hypertension. In conditions of a significant increase in pressure in the pulmonary artery, the load on the right ventricle increases and emptying of the right atrium is difficult, which causes hypertrophy of the right heart.
Due to the need to overcome significant resistance in the pulmonary artery and the development of sclerotic and dystrophic changes in the myocardium, the contractile function of the right ventricle decreases and its dilatation occurs. In this case, the load on the right atrium increases, which ultimately leads to decompensation of blood circulation in a large circle.
Complications of the operation
If pathology is not detected on time and untreated, complications in the form of progression of heart failure and pulmonary hypertension are inevitable.
Adequate treatment can significantly reduce the risk of all these complications and reduce the likelihood of a tragic development of events by 90-95%.
In rare cases, the following postoperative complications occur:
- infectious endocarditis – 1-4%;
- thromboembolism – 1%;
- restenosis or repeated narrowing after surgical correction – in 20% of patients within 10 years after surgery.
Without treatment, the inevitable progression of hemodynamic disorders, pronounced congestion in the lungs and other organs occurs, which leads to the development of complications and death. Complications of this disease are such as pulmonary embolism (especially in patients with atrial fibrillation), pulmonary edema, pulmonary hemorrhage, acute heart failure.
Both in the early and late postoperative periods, there is also the likelihood of complications:
- infectious endocarditis (the development of bacterial inflammation on valve flaps, including biological artificial);
- the formation of blood clots as a result of a mechanical prosthesis with the development of thromboembolism – separation of a blood clot and its release into the vessels of the lungs, brain, and abdominal cavity;
- degeneration (destruction) of an artificial bioplane with the repeated development of hemodynamic disturbances.
The doctor’s tactics boils down to regular examination of patients by echocardiography, monitoring of the blood coagulation system, life-long administration of anticoagulants and antiplatelet agents (clopidogrel, warfarin, dipyridamole, chimes, aspirin, etc.), antibiotic therapy for infectious diseases, abdominal surgery, and minimal therapeutic procedures gynecology, urology, dentistry, etc.
According to the area of narrowing of the left atrioventricular opening, 4 degrees of mitral stenosis are distinguished:
In accordance with the progression of hemodynamic disorders, the course of mitral stenosis goes through 5 stages:
- I – stage of complete compensation of mitral stenosis with the left atrium. There are no subjective complaints, however, direct signs of stenosis are auscultated.
- II – stage of circulatory disorders in the small circle. Subjective symptoms occur only during physical exertion.
- III – stage of pronounced signs of stagnation in the small circle and the initial signs of circulatory disorders in the big circle.
- IV – stage of pronounced signs of stagnation in the small and large circle of blood circulation. Patients develop atrial fibrillation.
- V – dystrophic stage, corresponds to stage III of heart failure
|Power||Qualitative determination of stenosis||Mitral foramen area (in cm 2)||Clinical signs|
|First||minor||more 3||lack of symptoms|
|The second||moderate||2,3 – 2,9||symptoms of the disease appear after exercise|
|The third||expressed||1,7 – 2,2||symptoms appear even at rest|
|The fourth||critical||1 – 1,6||severe pulmonary hypertension and heart failure|
|Fifth||terminal||clearance is almost completely blocked||the patient dies|
Depending on the type of anatomical narrowing of the valve opening, these forms of mitral stenosis are distinguished:
- as a “jacket loop” – valve flaps are thickened and partially spliced together, are easily separated during surgery;
- by the type of “fish mouth” – as a result of the growth of connective tissue, the valve opening becomes narrow and funnel-shaped, such a defect is more difficult to surgical correction.
Stages of the disease (according to A.N.Bakulev):
- compensatory – the degree of narrowing is moderate, the defect is compensated by hypertrophy of the heart, complaints are practically absent;
- subcompensatory – the narrowing of the hole progresses, the compensatory mechanisms begin to exhaust themselves, the first symptoms of distress appear;
- decompensation – severe right ventricular failure and pulmonary hypertension, which are rapidly exacerbated;
- terminal – the stage of irreversible changes with a fatal outcome.
Prognosis and prevention
Five-year survival in the natural course of mitral stenosis is 50%. Even a small asymptomatic defect is prone to progression due to repeated attacks of rheumatic heart disease. The postoperative 5-year survival rate is 85-95%. Postoperative restenosis develops in approximately 30% of patients within 10 years, which requires mitral recomissurotomy.
Prevention of mitral stenosis is the conduct of anti-relapse prevention of rheumatism, rehabilitation of foci of chronic streptococcal infection. Patients are monitored by a cardiologist and rheumatologist and undergo regular full clinical and instrumental examinations to exclude the progression of a decrease in the diameter of the mitral orifice.
The prognosis is unfavorable only in the absence of proper treatment – in the next 10 years 65% of such patients will die. After an appropriate operation for mitral valve stenosis, this figure drops to 8-13%.
Prevention of pathology and its relapses is the timely treatment of rheumatic and infectious diseases, maintaining a healthy lifestyle and attentive attitude to one’s own health.
Under these conditions, the risk of mitral stenosis, if it does not completely disappear, is significantly reduced, and the likelihood of a fatal outcome of an early detected defect is completely reduced to almost zero.
The prognosis of mitral stenosis without treatment is unfavorable, since death occurs in the outcome of the disease. The average age of patients with this defect is 45-50 years. Cardiosurgical treatment (as a method of a radical way of correcting anatomical and functional changes) allows prolonging life and improving its quality significantly in combination with the regular use of medications.
Doctor therapist Sazykina O.Yu.
Mitral stenosis is a commonly diagnosed acquired mitral heart valve defect:
- the disease is detected in approximately 90% of all patients with acquired heart defects;
- 1 person out of 50-80 thousand suffers from this disease;
- in 40% of cases this is an isolated pathology, in the rest – it is combined with other anatomical defects in the structure of the heart;
- the risk of the clinical manifestation of the disease increases with age: the most “dangerous” age is 40-60 years;
- women are more prone to this disease than men: among patients with this defect, 75% of the weaker sex.
Valve Disease Clinic
The clinical picture depends on the stage and degree of narrowing of the bicuspid valve. When narrowing to 3-4 cm1, complaints are absent for a long time, with critical stenosis (less than cm), complaints are always present.
The appearance of a patient with mitral stenosis is characterized by:
- Forced position – sitting with emphasis on the palm of your hand.
- “Mitral butterfly” on the face.
- Noisy heavy breathing.
- Severe weakness.
Due to pulmonary hypertension, patients complain of shortness of breath, which gradually becomes constant. Reduced cardiac output leads to cardialgia (heart pain is not angina pectoris). As a rule, pains are localized at the apex, accompanied by a sensation of interruptions, fading, or an uneven heartbeat.
In the supine position, the patient’s condition worsens. The symptom of “night apnea” – sudden asphyxiation during sleep is characteristic. Patients sleep on a high headboard, suffer from insomnia.
In the stage of decompensation (right ventricular dilatation), cardiogenic edema develops. Edema grows in the evening, localized in the lower extremities and have an ascending character. Drawing pains appear in the right hypochondrium due to stretching of the capsule of the liver, which protrudes from under the edge of the costal arch. In the abdominal cavity, fluid (ascites) accumulates, the saphenous veins of the abdomen expand (a symptom of the “jellyfish head”).
During dilatation of the right ventricle, a visible pulsation develops in the area of the costal angle (cardiac impulse), hemoptysis and pulmonary edema.
When listening to the heart, a complex of specific symptoms is revealed that make up the auscultatory picture in mitral stenosis:
- The opening tone of the bicuspid valve is heard before the first tone, with mitral stenosis due to the splitting of 2 tones into two components.
- Flapping first tone.
- At the second auscultation point is an accentuated second tone.
- At the apex of the heart there is a diastolic murmur, which amplifies after test physical activity in the presence of mitral valve stenosis.
- Extrasystoles, tachycardia can be heard.
Three heard tones form a specific symptom detected only with a given disease – the “quail rhythm”. With developing pulmonary edema, moist finely bubbling rales are heard in the lower parts of the pulmonary fields.
Auscultation with mitral valve stenosis is able to show abnormalities during their nucleation.
Etiology and risk factors
The causes of the disease in most cases are:
- rheumatic diseases (rheumatism, systemic lupus erythematosus, scleroderma) – 80-90% of cases;
- atherosclerosis – 6%;
- infectious diseases (tonsillitis, syphilis and other sexually transmitted diseases, sepsis, tick-borne diseases) – 6%;
- infectious endocarditis;
- cardiac muscle injuries;
- valve calcification of a non-rheumatic nature;
- heart tumors.
Thus, it can be noted that there is rheumatic and non-rheumatic mitral stenosis of the heart valve.
Risk factors are the frequency and severity of transmitted infectious diseases, inadequate treatment of autoimmune and other provocative diseases, and a genetic predisposition (maternal pathology is transmitted in 25% of cases).
Symptoms of pathology
Manifestations of the defect are divided into pulmonary, cardiac and general.
- Decreased performance.
- Forced sitting position.
- Pale skin combined with cyanosis.
- Difficult noisy exhalation.
- Cough for no apparent reason.
- Tendency to respiratory diseases.
- In the later stages – hemoptysis.
- Heart palpitations.
- Reduced blood pressure.
- Atrial fibrillation.
- Ascending edema of the lower extremities.
The first manifestation of the defect is pallor of the skin. As hypoxia progresses, acrocyanosis develops – blue lips, earlobes, fingertips. In the decompensation stage, cyanosis becomes common, the mucous membranes turn blue.
A specific symptom is characteristic – “mitral face” – pronounced pallor of the face in combination with a raspberry blush on the cheeks and blueness of the lips. Despite these symptoms, skin changes are not diagnosed.
The appearance of blood streaks in sputum is due to cardiogenic pulmonary edema.
Developing pulmonary hypertension is the basis of spasm of blood vessels of the microvasculature – capillaries, arterioles and venules.
Spasm of microvasculature exacerbates hypertension, resulting in damage to the vascular walls. Through damaged vessels, blood begins to flow into the lung tissue. In the process of lung self-cleaning, the blood mixes with mucus and is expectorated by the patient (hemoptysis).
The disease is characterized by the early onset of arrhythmia. Rhythm disturbances are caused by hypertrophy of the venous ventricle and left atrium, as a result of which the heart chambers cannot contract at the same time. The following types of arrhythmias are distinguished:
- Atrial fibrillation.
- Ventricular tachycardia and fibrillation.
- Atrial flutter.
- Atrioventricular blockade.
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The pressure gradient is the pressure difference between the left heart chambers. Normally, the pressure in the left ventricle is 33-45 mm Hg, in the atrium – 3-6 mm Hg.
With bicuspid valve stenosis, the pressure first becomes the same in both chambers. As the progression progresses, the pressure in the atrium becomes greater than in the ventricle, on the basis of which the following classification of the defect is carried out:
- Slight stenosis (gradient is 7-11 mm Hg).
- Moderate (12-20 mmHg).
- Significant (more than 20 mmHg).
The magnitude of the gradient also reflects the degree of pulmonary hypertension.
Symptoms with mitral stenosis are manifested gradually: at first they bother the patient only after physical exertion, then they are observed even at rest. For a clinic of mitral valve stenosis, it is characteristic that patients complain of:
- shortness of breath or cardiac asthma;
- cough, which may be dry at first, and then becomes moist – with a high content of sputum, foamy and even with an admixture of blood;
- fatigue and weakness;
- frequent dizziness and fainting;
- violation of thermoregulation;
- hoarseness of voice;
- frequent bronchitis and pneumonia;
- pain in the heart – more often from the back between the shoulder blades;
The patient’s appearance is characteristic: he is pale, and a febrile blush is visible on his cheeks, the tip of the nose, lips and fingers are cyanotic, the veins on the neck are swollen, swelling on the body and a swollen stomach can be noticeable.
Features in children
The causes of mitral stenosis in children can be systemic autoimmune diseases:
- Systemic lupus erythematosus.
In the vast majority of cases, the etiology of the defect in the child is untreated angina and the absence of bicillin prophylaxis after streptococcal infection.
The disease is characterized by the same hemodynamic changes as in adults, however, the clinic has some features:
- Lag in physical development.
- “Mitral face” rarely develops.
- The disease is not complicated by atrial fibrillation.
- The “quail rhythm” is rarely heard, the protodiastolic and prediastolic murmurs at the apex of the heart are more characteristic.
- Frequent fainting.
- Pronounced epigastric pulsation (up to the development of the “heart hump”).
- Conservative (preparation for surgery)
- Operational (valve replacement).
The prognosis without treatment is poor. The operation is carried out in the first month after diagnosis and is completed successfully in more than 90% of cases. The life expectancy of treated patients is 55-65 years.
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.