Overview
Rheumatic mitral stenosis is a heart valve disease left after heart inflammation caused by acute rheumatic fever, rheumatic mitral stenosis is the most common rheumatic heart disease. With the improvement of medical conditions in China and the improvement of people’s living standards, the incidence of rheumatic mitral stenosis is decreasing year by year. It usually takes more than 5 years to form mitral stenosis after acute rheumatic fever. Rheumatic mitral stenosis usually develops at the age of 40-50 years, and is more common in women than in men. The main manifestations of rheumatic mitral stenosis are dyspnea, cough and hemoptysis. The treatment of rheumatic mitral stenosis mainly consists of general therapy, interventional therapy and surgery.
Questions you may be concerned about
What are the most common complications of rheumatic mitral stenosis?
The most common complication of rheumatic mitral stenosis is atrial fibrillation.
The mitral valve is the valve between the left atrium and the left ventricle. After mitral stenosis, the flow of blood from the left atrium to the left ventricle is blocked, and part of the blood accumulates in the left atrium, resulting in an increase in the pressure in the left atrium and subsequent enlargement of the atrium, fibrosis of the atrial wall, and other lesions.
These pathologic changes are the basis for persistent atrial fibrillation, which is the most common complication of rheumatic mitral stenosis and the first symptom in some patients at the time of diagnosis.
Other common complications of rheumatic mitral stenosis include acute pulmonary edema, thromboembolism, right heart failure, and infective endocarditis. It is recommended that patients be admitted to the hospital for aggressive treatment to avoid further progression of the disease.
Causes
The main cause of rheumatic mitral stenosis is acute rheumatic fever. Some patients do not have a history of acute rheumatic fever, but have a history of recurrent upper respiratory tract streptococcal infections.
Symptoms
Rheumatic mitral stenosis usually presents when the mitral valve is moderately stenotic (mitral orifice area <1.5 cm2).
1. Symptoms
(1) Dyspnea
Dyspnea is the earliest and most common symptom, and can be triggered by exercise or emotional stress. As the disease progresses, the symptoms of dyspnea worsen, and may occur at rest, or in paroxysms at night, or even with sitting breathing.
(2) Cough
Cough is also a common symptom, mostly after sleep or labor, can be dry cough without sputum or foamy sputum. When infection occurs, mucus sputum or pus sputum can be coughed up.
(3) Hemoptysis
Hemoptysis in pulmonary stasis mainly manifests as blood in sputum. When combined with acute pulmonary edema, pink foamy sputum can be coughed up. In severe cases, a large amount of blood may be spat out at an early stage due to rupture of bronchial varices, which is called hemoptysis.
(4) Other symptoms
When the left atrium is enlarged or the left pulmonary artery is dilated, peripheral compression symptoms may appear, such as hoarseness of voice by compressing the recurrent laryngeal nerve, dysphagia by compressing the esophagus, etc. In right heart failure, abdominal distension may appear. In right heart failure, gastrointestinal symptoms such as abdominal distension, nausea and loss of appetite may occur.
2. Physical signs
(1) Mitral facial features
When rheumatic mitral stenosis develops into the advanced stage, the patient will have mitral facial features such as dark color, purplish cheeks, and mild cyanosis of lips and mouth.
(2) Heart murmur
The characteristic murmur of rheumatic mitral stenosis is diastolic rumbling murmur in the apical part of the heart, which is obvious in the left lateral position and often accompanied by diastolic tremor. In pulmonary artery dilatation resulting in relative pulmonary valve insufficiency, a decreasing wind-blowing early diastolic murmur can be heard in the 2nd to 4th intercostal space at the left sternal border. In right ventricular dilatation with tricuspid valve insufficiency, a holosystolic wind-blowing murmur can be detected in the 4th and 5th intercostal spaces at the left sternal edge.
(3) Heart sounds
In the early stage of the disease, the first heart sound can be heard in the apical region and open heart sound. In the late stage of the disease, the first heart sound is weakened due to the calcification and stiffness of the mitral valve, and the open heart sound disappears.
Examination
1. Chest X-ray
Chest X-ray generally shows signs of pulmonary stasis due to elevated pulmonary venous pressure, such as enlarged pulmonary hilums and increased upper lung texture. In interstitial pulmonary edema, transverse linear shadows can be seen in the lower part of the lung fields. Cardiac shadow shows enlargement of the left atrium, such as posterior anterior chest radiograph shows double atrial shadow, right anterior oblique chest radiograph shows left atrium compressing the lower esophagus, and so on.
2. Electrocardiogram
In mild cases, the electrocardiogram may not show any obvious abnormality. In patients with severe mitral stenosis, there may be “mitral P-wave” with P-wave width >0.12 seconds, accompanied by tangential signs, suggesting that the left atrium is enlarged.
3. Echocardiography
Echocardiography is the most sensitive and reliable means of confirming the diagnosis of this disease. m-mode echocardiography shows that the anterior leaflet of the mitral valve shows a “wall-like” change (the slope of the EF decreases, and the A peak disappears), and the anterior and posterior leaflets show isotropic motion. Two-dimensional or cross-sectional echocardiography can directly visualize the thickening and deformation of the mitral valve leaflets, abnormal activity, stenosis, left atrial enlargement and other lesions, which can lead to a clear diagnosis.
Diagnosis
Combined with a history of acute rheumatic fever or recurrent upper respiratory tract streptococcal infections, the patient presents with major symptoms such as dyspnea, cough, hemoptysis, etc., and physical examination reveals a characteristic diastolic rumbling murmur in the apical region, changes in the heart sounds, a hyperactive first heart sound, and a hyperactive second heart sound in the area of the pulmonary artery valve. Auxiliary examination reveals pulmonary stasis and signs of left atrial enlargement, and electrocardiogram reveals mitral P wave, right ventricular hypertrophy with strain, especially echocardiography shows thickening, deformation, abnormal activity, and stenosis of mitral valve leaflets, which can be definitively diagnosed as rheumatic mitral valve stenosis.
Treatment
1. General treatment
Mild rheumatic mitral stenosis patients do not need special treatment, can be appropriate activities, but need to avoid excessive physical labor and strenuous exercise. Patients with rheumatic mitral stenosis need long-term anti-rheumatic fever treatment with benzylpenicillin. As rheumatic mitral stenosis has the possibility of complicating acute pulmonary edema, patients need to try to avoid triggers causing acute pulmonary edema, such as full meals, stool exertion, emotional fluctuations, fatigue, acute infections and so on. For those with concurrent atrial fibrillation, anticoagulation should be performed. Mild to moderate patients can be followed up every 2 to 3 years, while severe patients need annual follow-up and echocardiography.
2. Interventional therapy
Percutaneous balloon mitral valve dilatation (PBMC) is the treatment of choice for simple rheumatic mitral stenosis. Patients experience significant symptomatic and hemodynamic improvement after the procedure and have fewer complications. Short- and long-term outcomes in those suitable for intervention are similar to those of surgical treatment.
The indications for percutaneous balloon mitral valve dilatation include: moderate to severe simple mitral stenosis (mitral orifice area ≤1.5 cm2); Wilkins ultrasound score <8; no thrombus in the heart; and no combination of mitral valve insufficiency and other cardiac valvular diseases.
Contraindications for percutaneous balloon mitral valve dilatation mainly include: poor valve condition unsuitable for interventional therapy; left atrial thrombosis; active stage of acute rheumatic fever; and the combination of more than moderate mitral valve insufficiency and other heart valve diseases.
3.Surgery
Surgical treatment mainly includes mitral valve separation and prosthetic valve replacement. The purpose of surgery is to expand the area of the mitral valve orifice, restore normal blood flow dynamics, relieve symptoms and improve cardiac function. There are two types of mitral valve separation: closed mitral valve separation and direct-vision mitral valve separation, in which the indications and therapeutic effects of closed mitral valve separation are similar to those of interventional therapy, and it is seldom used nowadays. Directly visualized mitral valvotomy is suitable for patients with severe leaflet calcification, left atrial thrombosis, and lesions involving the tendon cords and papillary muscles. Directly visualized mitral valvotomy has a better hemodynamic improvement, and the operative mortality rate is less than 2%. Prosthetic valve replacement is indicated in patients with severely calcified leaflet deformities, inappropriate for interventional therapy or mitral valvotomy, and in combination with more than moderate mitral valve insufficiency. The mortality rate (3%~8%) and complications of prosthetic valve replacement are higher than those of mitral valvuloplasty, but those with successful replacement surgery have better recovery of cardiac function.
4. Treatment of acute pulmonary edema
Consistent with the principle of acute left heart failure, adopt semi-recumbent position or sitting position, give morphine or pethidine, pressurized high-flow oxygen, oxygen with alcohol and other defoamers, can reduce dyspnea, improve ventilation; furosemide and other diuretics and sodium nitroprusside, etc., to reduce the cardiac load, reduce the pressure of the pulmonary circulation; at the same time, hormone therapy is given, which can help to control pulmonary edema.
Questions you may be concerned about
Is benzylpenicillin used to treat rheumatic mitral stenosis?
Benzylpenicillin can be used for the treatment of rheumatic mitral stenosis, and has a good effect on active rheumatic fever.
Benzylpenicillin belongs to the penicillin class of broad-spectrum antimicrobial drugs, strong on gram-positive cocci, gram-positive bacilli, gram-negative cocci, etc., because of the benzylpenicillin drug absorption is particularly slow, the blood concentration is low, suitable for long-term use of penicillin drugs for patients with chronic diseases.
Benzylpenicillin can not be used in large doses, large doses will produce psychiatric symptoms of lethargy, delirium, or even unconsciousness. The use of benzylpenicillin need to pay attention to have a history of penicillin allergy patients with caution, please standardize the use of medication under the guidance of a physician.
Hazards
Patients with rheumatic mitral stenosis may suffer from dyspnea, cough, hemoptysis and other symptoms, which seriously affects daily life and work. Rheumatic mitral stenosis can cause a variety of complications, such as atrial fibrillation, acute pulmonary edema, thromboembolism, right heart failure, lung infection and so on. Among them, atrial fibrillation is the most common complication in the early stage, which is caused by the enlargement of the left atrium and fibrosis of the atrial wall. Atrial fibrillation can reduce the volume of cardiac excretion by 20% to 25%, which causes the patient to experience severe respiratory distress and even acute pulmonary edema. Acute pulmonary edema is a serious complication in patients with severe rheumatic mitral valve, which can be induced by satiation, stool exertion, emotional fluctuations, exertion, acute infection, etc. If not treated in time, the lethality rate is high. Rheumatic mitral stenosis is easily combined with pulmonary infection due to pulmonary stasis and increased pulmonary venous pressure, and pulmonary infection will further aggravate the condition.