Guest: Professor Sun Zongquan, Department of Cardiac Surgery, Concordia Hospital Dr. Xia Jiahong
Topic: Rheumatic heart disease is a heart disease caused by rheumatism, and cold and humidity are important predisposing factors. Although the incidence of rheumatic heart disease has decreased significantly in the past 30 years due to the improvement of people’s living conditions and the improvement of pretreatment measures, it still has a high incidence in many areas. So, in this episode, we will talk about the prevention and surgical treatment of rheumatic heart disease. Xia Jiahong, Department of Cardiac Surgery, Wuhan Union Hospital
Surgical treatment of rheumatic heart disease
First segment (10 minutes)
[Host] Hello, viewers! This is the live broadcast of Hubei TV’s Health Club, welcome to watch and participate in our program. Rheumatic heart disease is a heart disease caused by rheumatism, and cold, humidity and streptococcal infection are important triggering factors. Although the incidence of rheumatic heart disease has decreased significantly over the past 30 years due to improved living conditions and better preventive measures, it still has a high incidence in many regions, especially in the Northeast. So, in this episode, we will talk about the prevention and surgical treatment of rheumatic heart disease. Here we have Professor Sun Zongquan, Director of Cardiac Surgery at the Union Hospital of Huazhong University of Science and Technology. Hello!
[Director Sun] Hello! Hello everyone!
[Moderator] And Dr. Jiahong Xia. Hello!
[Jiahong Xia] Hello! Hello everyone!
[Moderator] Meanwhile, we have also opened three hotlines on our broadcast site, so if you have questions about rheumatic heart disease and need to consult experts, you can call our live hotlines at any time (027) 96759129, 87329101, 87329102. director Sun. What do you first tell us about rheumatic heart disease?
[Director Sun] When it comes to rheumatic heart disease, first of all, let me explain what rheumatic disease is. The heart damage is mainly caused by heart valve lesions, so rheumatic heart disease is also called rheumatic heart valve disease.
[Host] Director Sun, just now you said that rheumatic heart disease is also known as wind heart valve disease, rheumatic heart disease is related to the heart valves. How many valves are there in the human heart and what is their role?
[Director Sun] There are four sets of valves in the heart of each person. These are the aortic valve that connects the left ventricle to the aorta, the pulmonary valve that connects the ventricle to the pulmonary artery, the mitral valve that connects the left atrium to the left ventricle, and the tricuspid valve that connects the right ventricle. They all act as one-way valves so that blood can only flow from one direction to the other without backflow. Each valve consists of two to three leaflets, which are thin, smooth and flexible when normal.
Rheumatic heart valve disease is common, and changes in the valve itself are more obvious. For example, valve thickening, calcification or further development of scar formation, resulting in valve deformation, stenosis or incomplete closure and loss of normal valve function. This results in abnormal hemodynamic lesions such as blood flow failure or regurgitation, and heart valve disease. If the valve is deformed and the blood flow is not smooth, it is called valve stenosis, such as mitral stenosis, aortic stenosis, etc. If the valve is not closed tightly and the blood flow is regurgitated, it is called incomplete closure.
In simple terms, the heart valve is the door, valve stenosis is equivalent to the door can not be opened, valve closure is equivalent to the door can not close. (with a valve anatomy diagram store)
[Moderator] So, what causes wind heart disease?
The etiology of wind heart disease is mainly related to group A streptococcal infection. Most patients have a history of pharyngitis, tonsillitis, and upper respiratory tract infections, and group A streptococci cause the body to produce antibodies that cross-react with connective tissue, which act not only on the streptococci themselves, but also on their own connective tissue, causing rheumatic lesions. Only a very small number of people infected with streptococci, 1 to 3%, develop rheumatic disease, so the onset of the disease is related to the reactivity of the body.
Acute rheumatic fever can occur at any age, but it is common in children and adolescents aged 5 to 15 years old, with equal incidence in men and women, and can recur. The incidence is relatively high in northeast, north, central and east China, and cold and humidity are important predisposing factors.
[Moderator] Since cold and damp are the main predisposing factors, is it possible to prevent it by preventing dampness and keeping warm? (How to prevent the occurrence of wind heart disease?)
[Director Sun] Yes, ……
The main prevention of rheumatic heart disease is to prevent recurrent attacks of rheumatic fever. Because it is related to streptococcal infection, prevention of streptococcal infection is an important part of prevention of rheumatic fever. ①Prevent upper respiratory tract rationale infection, often participate in physical exercise to improve the body resistance. ②Once the upper respiratory tract infection, pharyngitis, otitis media, tonsillitis and other streptococcal infections, should be actively and thoroughly treated with antibiotics, preferably with penicillin, penicillin allergy can be erythromycin. ③Recurrent tonsillitis is feasible with tonsillectomy ④Patients with rheumatism can be injected with long-acting penicillin 1.2 million units intramuscularly once a month to prevent reinfection. ⑤It is also necessary to prevent the dampness and coldness of the living environment. The incidence rate is 10 times higher without preventive measures than with preventive measures, indicating the importance of prevention.
[Moderator] Does wind heart valve disease always require surgery?
[Director Sun] If the normal heart valves are invaded by rheumatic fever or bacteria, resulting in deformation, thickening, adhesion, calcification or due to trauma or congenital malformation, etc., a certain group or two groups of valves become narrowed or incompletely closed, losing the one-way valve role, and the lesions of the valves cannot be effectively treated by closed dilatation or shaping, causing poor blood flow, hemodynamic disorders, and finally heart enlargement to The heart eventually enlarges to heart failure, pulmonary stasis, hepatomegaly, ascites, etc. In this case, the original diseased valve must be surgically removed and replaced with an artificial heart valve under extracorporeal circulation to restore the physiological function of the one-way valve and to relieve or alleviate the symptoms. Thousands of patients around the world are rehabilitated every year as a result of this procedure. It has been more than 30 years since the first valve replacement surgery in China. The clinical results are positive.
So, what are the main symptoms of wind heart valve disease?
[About 50% of patients have a history of typical rheumatic fever, fever, excessive sweating, panic, painful wandering joint redness and swelling, and functional impairment. From rheumatic fever to the formation of heart valve disease, it takes about 2 years at the shortest, and most of them form serious valve lesions in 5~10 years. Once the heart valve stenosis or incomplete closure, the patient’s symptoms become more and more severe.
There is also ① exertional dyspnea, shortness of breath, cough, paroxysmal dyspnea at night, telangiectatic breathing, and even coughing up blood and blood in sputum. It is mainly caused by pulmonary stasis. (2) General fatigue, dizziness, and even fainting, followed by swelling of the lower limbs, decreased exercise tolerance, and limited physical work, mainly caused by reduced cardiac blood output. ③15% of patients have chest pain, 20% of patients have thromboembolism, stroke, caused by dislodgement of cardiac thrombus, 80% of patients with embolism have atrial fibrillation, and embolism may recur.
[Moderator] Are there any differences between these symptoms and some other symptoms of heart disease?
[Director Sun] Yes. For example, patients with mitral valve disease usually have a flushed face, which is called a “mitral face”. So, if the lady has a flushed face, you should consider whether she has wind heart disease. Except for those who wear makeup, of course.
[Moderator] How do you diagnose wind heart valve disease?
[Director Sun] When you have heart discomfort, you should first go to the hospital for a routine examination. Take a chest x-ray and an electrocardiogram. X-rays and electrocardiograms can look at pulmonary stasis and heart enlargement, understand atrial fibrillation, and cardiac hypertrophy. The most sensitive and specific non-invasive test is echocardiography (color ultrasound), which can determine the degree of damage of valve lesions, whether the valve is stenotic or incomplete, the area of valve opening, the degree of stenosis, the area of regurgitation, whether the incomplete closure is mild or severe, and can also measure cardiac function indicators.
[Moderator] How should wind heart valve disease be treated?
[Director Sun] Medication, interventional therapy and surgery are available.
Drug treatment is mainly for acute and chronic heart failure. Once heart failure occurs, the patient must be hospitalized, and the general treatment includes bed rest, low-salt diet, oxygen, etc. Some medications are administered.
For simple mitral stenosis, percutaneous perforation of the mitral balloon can be used to dilate the mitral valve, i.e., interventional therapy, which can enlarge the mitral orifice area to more than 2.0 cm. Interventional treatment can be performed without opening the chest, with little damage, fast recovery and positive recent results, but it must be performed in a hospital with conditions.
[There are two types of surgical treatment methods: one is valvuloplasty and the other is valve replacement. Valvuloplasty is mainly for atrioventricular valve (mitral and tricuspid valves) insufficiency or combined stenosis at the same time using different repair methods, these methods include valve stenosis or tendon adhesions by junctional dissection, adhesion separation, partial leaflet resection and repair, tendon shortening, tendon or papillary muscle transplantation, valve annulus enlargement caused by insufficiency of closure when the application of artificial ring to reduce the ring. Heart valve replacement is an important treatment for unrepairable valve lesions. In other words, one or more of the patient’s irreparable valves are removed and replaced with an artificial heart valve.
[Moderator] Can an artificial heart valve replace a human heart valve? How does it perform?
[Director Sun] Yes, there are two main types of artificial heart valves, one is a biological valve and the other is a mechanical valve. Biological valves are made from biological materials, such as porcine aortic valves and bovine pericardial valves, which are treated with glutaraldehyde and then made. The advantage is the central flow type, good hemodynamic performance, and the patient does not need lifelong anticoagulation, the disadvantage is that there is 12-20% valve failure 8-12 years after valve replacement, so it is more ideal to replace the biological valve in the elderly.
[Director Sun] There are also mechanical valves made of mainly titanium steel, cobalt-nickel alloy or pyrolytic carbon, and the main advantage is the mechanical durability of the valve, up to 30-100 years. The main disadvantage is the need for lifelong anticoagulation therapy. Due to the high durability, mechanical valves are predominantly used for middle-aged and young adult valve replacement.
The quality of the artificial valve is evaluated mainly from its good mechanical properties, such as durability, valve sound, hemodynamic properties, mainly the effective valve area and its histocompatibility, such as less thrombosis, no hemolysis, etc.
Domestic artificial heart valves have approached and reached the international level and have been used in the clinic for more than 30 years. The choice of domestic and imported valves is based on the needs of the patient’s condition and depends on the patient’s economic conditions. At present, half of the patients in our hospital choose imported valves and half choose domestic valves, and the results are very good.
[Moderator] Is there a time requirement for valve replacement?
[Director Sun] In rheumatic heart disease, the damage is not only limited to the valve, but also to the heart muscle, and as the disease progresses, the damage to heart function increases. The indication and timing of surgery depends on the extent of valve damage. Whether one heart valve is damaged or multiple valves are damaged requires a thorough examination in the hospital to determine. Not all patients with rheumatic heart disease need surgery, and not all surgery is better as early as possible, let alone waiting until the condition is severe, increasing the risk of surgery or even losing the opportunity to operate. This is often encountered in our clinical work in such patients with significantly enlarged heart and severely impaired cardiac function, which increases the risk of surgery and the cost of surgery. Therefore, it is recommended that patients with wind heart disease should see a specialist at a large hospital to find out what the extent of their condition is, how many valves are damaged, and it is very necessary to consult with a specialist, with a specialist in cardiovascular medicine and surgery.
[Moderator] Is it possible for all patients with wind heart disease to have this surgery?
[Director Sun] With the advancement of technology and the improvement of the surgical level, most of the patients with wind heart disease can have the surgery especially many of the middle and late stage critical wind heart disease also have the opportunity to have the surgery. Of course, if the liver and kidney damage is serious, you can’t do it, you have to first carry out medical treatment, and then consider surgery when your condition improves.
[Moderator] If a patient has several valves damaged at the same time, can several heart valves be replaced at the same time?
[Director Sun] Yes, there are four heart valves in the human body. If the rheumatic lesion has mainly invaded the mitral valve or the aortic valve, or even if both valves have been damaged, it is a joint valve lesion, and the surgeon can decide whether to replace a single valve or a double valve based on a thorough preoperative examination and a careful intraoperative exploration. Surgical replacement of mitral and aortic valves (double valves) and simultaneous tricuspid valvuloplasty for patients with multiple valve lesions is done frequently in our clinical work. We have also done three valve replacements with good results.
[Moderator] What should we pay attention to after valve replacement for women and children?
[Director Sun] After valve replacement in women of childbearing age, if the hemodynamics and cardiac function improve significantly, pregnancy can be allowed 2~3 years after valve replacement. However, it is necessary to visit the hospital during pregnancy and to abort the pregnancy once the threat of circulatory overload and increased cardiac burden is detected in the patient. If all aspects are in good condition, hospitalization and spontaneous delivery are possible when entering the due date, great care should be taken. For women who use caesarean section, stop Warfarin a day earlier to prevent heavy postpartum bleeding and restart anticoagulation therapy 48-72 hours after the operation.
[Director Yin] Children and adolescents are in the growth and development period, try to avoid valve replacement surgery, only when it is difficult to correct the valve lesion by medical treatment or plastic surgery, and the heart function is severely impaired, valve replacement surgery is done, children mostly choose mechanical valves, not biological valves, because the calcium metabolism in childhood is vigorous, biological valves are easy to calcify and deteriorate.
What should I pay attention to after [moderator] heart valve replacement?
[Director Sun] Early considerations after valve replacement
The first three months after surgery is an important stage to overcome the surgical trauma and recover the body, the following should be noted.
(1) Continue to take various medications prescribed by the doctor on time, commonly used medications include anticoagulants, cardiac diuretics, anti-arrhythmics, etc. (2) Learn to adjust the dosage of anticoagulant medications on your own. Due to individual differences, each patient requires a different dose of anticoagulants. The doctor has initially mapped out the patient’s anticoagulant dose at the time of discharge, and should conduct regular laboratory tests after discharge to further adjust his or her anticoagulation therapy. (See later for details.) (3) Prevent infections, especially respiratory inflammation, periodontitis, skin boils, urinary tract infections, etc. They should be controlled as soon as they are detected. Intermittent or persistent fever of unknown origin should not be treated indiscriminately with antimicrobials. You should seek medical attention promptly. To avoid delaying treatment. (4) Appropriate activity should be maintained after surgery in order to enhance physical fitness and improve quality of life while recovering from cardiac function. The amount of activity should be measured and gradual, so as not to cause shortness of breath. Do not spend the whole day in bed to rest. (5) Arrange your early recuperation life, keep your spirit happy, relaxed, optimistic and confident. (6) Do not avoid eating, pay attention to increase nutrition, supplement protein and vitamins. It is not advisable to eat too salty food. Patients with poor heart function should limit the amount of water they drink, and should not eat a lot of thin rice and soups, so as not to increase the burden on the heart with too much liquid. (7) A detailed examination (including physical examination, electrocardiogram, chest X-ray, echocardiogram, etc.) should be performed at the hospital three months after the operation, and the medication should be adjusted according to the examination results, and health guidance for future life and work should be made.
When to return to work and labor after valve replacement
After heart valve replacement, the speed and extent of recovery depends on the functional status of the heart and the general physical condition. In general, recuperation is the main focus for three months after surgery. After three months, most patients can resume normal physical activities and work if their heart function recovers satisfactorily and they are in good health. A small number of patients with very poor preoperative cardiac function and late surgery can also engage in light work after surgery, although there is significant improvement.
(XII) Commonly used anticoagulant drugs
The following drugs can be used for anticoagulation after valve replacement: warfarin, new anticoagulation tablets, and heparin. Aspirin can also be used as an adjunctive anticoagulant. The most commonly used is the oral formulation of warfarin. Because of the long half-life of warfarin, it may be temporarily replaced by intravenous or subcutaneous heparin during discontinuation of warfarin if secondary surgery or other procedures other than cardiac surgery are required. Warfarin is administered once a day, and the daily dosing time can be fixed at 8:00 p.m. Always remember to take the medication on time every day.
(XIII) Adjustment of anticoagulant dose
Due to individual differences, the amount of anticoagulants used after flap replacement varies from person to person. Clinical observation shows that some people need warfarin 7 mg daily, while others only need 0.5 mg. However, most patients use about 3 mg of warfarin per day. The warfarin dosage for each individual is relatively stable, with some fluctuations over time, but the range of fluctuation is not large. Each patient should figure out his or her anticoagulant dosage as soon as possible and have regular laboratory tests to adjust it appropriately. After discharge from the hospital, the patient should be given the initial dose of anticoagulation, and be tested every 3-5 days, and learn to adjust the dosage according to the anticoagulation standard, and after the anticoagulation becomes more stable (about one month), the patient can be tested once a week. -After the anticoagulation is more stable (about one month), the test can be performed once a week. Anticoagulation therapy after valve replacement is very important and can be the key to ensuring good valve function. Patients must take this seriously and learn to read their labs as soon as possible and adjust their own medications with reference to anticoagulation criteria to improve their quality of life. Anticoagulation therapy is not difficult and should not be seen as a burden by the patient, but rather as a meal that is essential to their daily life. If there is any doubt about anticoagulation therapy, especially in the first 1-2 months after discharge, if you are not sure how to adjust anticoagulation medication, you should consult your doctor promptly.)
[What should I do if I need to have a tooth extraction or other surgery after flap replacement?
The best time to have a tooth extraction or other surgery after valve replacement is when your heart function is in good condition. If you are on long-term anticoagulation, you should suspend anticoagulation for two days prior to surgery to prevent postoperative bleeding, or for emergency surgery, special hemostasis and anti-bleeding treatment is required. The surgeon will carefully stop the bleeding during the procedure, and you can continue anticoagulation 24 to 48 hours after the procedure when there is no blood leakage.
[What should I pay attention to when taking other medications after flap replacement?
After valve replacement, patients may need to take other medications for other diseases at the same time as anticoagulant medications. This is known as “synergism” in medical terms. Drugs with synergistic effects include aspirin, heparin, etc. Care should be taken to prevent bleeding when using these drugs, and the anticoagulant should be reduced if necessary. There are other drugs that can weaken the effect of anticoagulants, called “antagonistic effect”, and drugs with antagonistic effect include vitamin K and some sleeping pills. When using these drugs, the dosage of anticoagulants should be increased appropriately to prevent clotting. The increase or decrease of anticoagulant dosage should be guided by experienced doctors, preferably with the support of laboratory tests.
[Can a female patient have a baby after valve replacement?
Women who have had a bioprosthetic valve replaced can have a normal pregnancy and delivery. However, it is important to note that (1) pregnancy should not be considered until anticoagulants have been discontinued at least six months after valve replacement and cardiac function has recovered well. (2) Prevent perinatal cardiac insufficiency, especially during pregnancy. Women with mechanical valve replacements should be considered carefully because of the need for lifelong anticoagulation. This is because (1) there is a reported risk of fetal malformation when warfarin is taken during the first trimester of pregnancy. (2) There is an increased risk of bleeding during anticoagulation for pregnancy and delivery. Of course, there are reports of successful pregnancy and delivery after mechanical flap replacement. We recommend that pregnancy and delivery after mechanical valve replacement should be avoided. However, if you decide to have a child, you should consult more with your cardiologist and obstetrician and gynecologist for good perinatal anticoagulation and health care.
What should I do if I have an irregular heartbeat after [Director Sun] valve replacement?
When you feel an irregular heartbeat, you should visit the hospital to find out the type of arrhythmia. Atrial premature beats have less impact on cardiac function and can be corrected with adequate rest and digitalis. Ventricular premature beats should be controlled as early as possible. Measures include rest, potassium supplementation, injection of lidocaine, and the administration of slow-rhythm drugs, but always under the guidance of a doctor. Temporarily discontinue digoxin in case of bradycardia (heart rate less than 60 beats/min) and gradually resume digoxin application after the heart rate is accelerated (greater than 70 beats/min). If the heart rate is still slow after stopping digoxin and there is dizziness, palpitations and other discomfort, promptly seek medical advice.
Heart valve disease is often associated with atrial fibrillation. Atrial fibrillation is still present 3 months after surgery, and defibrillation can be performed in the hospital when cardiac function recovers better. If atrial fibrillation is recalcitrant, has a long history, defibrillation is unsuccessful or acute patients do not have to be reluctantly defibrillated to avoid danger. It is sufficient to take digitalis preparations along with anticoagulation therapy to control the heart rate from being too fast or not slow.
How to review and follow up after [Director Sun] valve replacement?
We warmly welcome every patient to keep in touch with our hospital frequently after heart valve replacement. If possible, it is best to come to our outpatient clinic for follow-up. Write to us proactively or respond positively to letters from our follow-up team. On the one hand, we will understand your health status and provide health guidance, and on the other hand, it will help to improve our work, especially to promote the level of medical science in our hospital.
Address: Department of Cardiac Surgery, Wuhan Union Hospital 430022, Wuhan, China
Note: MRI is prohibited for patients with metallic flaps and avoid entering the area of strong magnetic field!