Rheumatic heart disease is a heart disease caused by the activity of rheumatic fever, which involves the heart valves. According to the incomplete statistics of the World Health Organization, there are more than 15 million patients with rheumatic heart disease worldwide, and 500,000 new patients suffer from acute rheumatic fever every year. The disease is mainly caused by group A hemolytic streptococcal infection and is an autoimmune disease. It occurs in winter and spring, in cold and humid environments, and its first occurrence is in young adults.
Disease Introduction
The incidence of rheumatic heart valve disease lesions involving each valve of the heart varies, according to the results of the study: mitral valve is 100%, of which 46.7% are simple mitral valve lesions, which is the highest proportion, followed by mitral valve combined with aortic valve, simple aortic valve, tricuspid valve and pulmonary valve. The lesions are mainly edema and oozing at the margins and base of the valve and gradually expand to the entire valve, even involving the tendon and papillary muscles, resulting in fusion of the leaflets in the junctional area, fusion and shortening of the tendon, and fibrosis, stiffness, curling, and calcification of the leaflets, leading to stenosis or incomplete closure of the valve opening. Valve stenosis: valve junction adhesions, thickening, stiffening, incomplete opening, and small valve orifices that impede normal blood flow. Inadequate valve closure: the tendon and papillary muscles are enlarged, shortened, and sclerotic, and the valve does not close completely, resulting in regurgitation of blood.
Pathophysiology
Under normal conditions, regardless of cardiac output, there should be no obstruction to blood flow between the left atrium and the left ventricle. When the mitral orifice narrows to approximately 2 cm2, a mild mitral stenosis is formed, hemodynamic changes occur, and blood flow from the left atrium to the left ventricle is obstructed. This causes an increase in left atrial pressure, which can be clinically symptomatic.
Elevated left atrial pressure can lead to increased pulmonary venous and pulmonary capillary pressures, resulting in respiratory distress. The pathophysiology of mitral stenosis is clinically divided into two phases: the first phase is the chronic pulmonary stasis phase, in which the patient may have no obvious symptoms at rest but may experience dyspnea due to increased heart rate during fatigue or emotional stress; the second phase is the pulmonary hypertension phase, in which the degree of pulmonary hypertension is related to the degree of valve stenosis. If the pulmonary artery pressure exceeds 60 mmHg, the patient may experience pulmonary edema and increased dyspnea during physical activity, rapid heartbeat, pregnancy, etc.
The normal aortic valve orifice area is 2.5-3.5 cm2, and the valve gradually becomes stenotic due to pathological changes. If the orifice area is reduced to 1 cm2, the left ventricular blood drainage is blocked and the left ventricular systolic pressure increases, resulting in an increase in the pressure gradient of the aortic valve and the patient’s symptoms. If the orifice area is reduced to 0.7 cm2, the stenosis is severe, the left ventricular wall may be significantly hypertrophied, myocardial oxygen consumption increases, and the coronary artery blood supply decreases, resulting in myocardial ischemia and angina pectoris. In individual patients, the cardiac output cannot be increased during activity, which may cause cerebrovascular dysfunction and syncope.
Disease classification
The number of valve sites involved in rheumatic heart disease can manifest as one or several valve lesions in the mitral, tricuspid, and aortic valves. Combined heart valve disease is a disease that involves two or more heart valves at the same time. The most common of these is mitral valve combined with aortic valve double lesions, which account for approximately 48%-87% of combined valve disease.
Clinical manifestations
Symptoms of the disease
The initial attack of rheumatic fever does not cause immediate changes in valve openings, and it often takes several years or even more than a decade for changes in valve openings to develop. Therefore, there are often no obvious symptoms in the early stage of the disease, but later on, the disease manifests itself as panic and shortness of breath, weakness, cough, limb edema, cough, hemoptysis, until heart failure, causing life-threatening. Clinically, depending on the degree of progression of the disease, the following are the main manifestations.
Palpitations and shortness of breath after activity, or even dyspnea, telangiectatic breathing, and inability to lie down at night.
Cough and cough with blood after slight activity or exertion, easily catching cold and flu.
Loss of appetite, which means that eating is not good for a period of time, stasis of blood in the gastrointestinal tract may not be digested well and bloating occurs. Decreased urine output, swelling of the lower limbs, abdominal distension, ascites, enlarged liver and spleen, etc.
Most of the patients have purplish red cheekbones and lips, i.e. “mitral facies”.
Palpitations are often caused by atrial fibrillation or arrhythmias. Rapid atrial fibrillation causes discomfort, and even difficulty breathing or aggravates it, prompting patients to seek medical attention. Atrial fibrillation is also a major cause of atrial tethering and even stroke.
Chest pain , caused by simple valve disease, is usually ineffective with nitroglycerin.
Once the above mentioned conditions usually occur, you should go to your local hospital this morning for a checkup. A heart ultrasound can clarify the presence of rheumatic heart valve disease.
Disease Hazards
Patients with rheumatic heart disease are prone to respiratory infections, which are manifested by a decrease in resistance and easy to develop cold symptoms. Mainly on the basis of pulmonary stasis, it is easy to combine bacterial infection and aggravate heart failure. At the same time, patients with wind heart disease may experience exertional panic and shortness of breath, decreased physical tolerance, and the quality of life is significantly affected. At the same time, there are the following main hazards Third Military Medical University Xinqiao Hospital Cardiovascular Surgery Department Ma Ruiyan
Arrhythmia: The most common type of arrhythmia is atrial fibrillation (AF), which is the most common arrhythmia in cardiovascular disease, with an incidence of more than 50%. Atrial fibrillation can lead to poor cardiac function, making the patient feel uncomfortable, and most importantly, it can lead to intra-atrial thrombosis.
1. Thromboembolism: A large left atrium combined with atrial fibrillation can easily lead to thrombus formation, and thrombus dislodgement can cause embolism. Cerebral embolism can cause hemiplegia and aphasia; arterial embolism of limbs causes ischemia and necrosis; deep vein thrombosis leads to pulmonary artery embolism.
2, infective endocarditis: occurs in the early stages of valve disease, bacteria attached to the surface of the valve leaflets, gathered to form superfluous, infected bacteria commonly streptococcus, staphylococcus, enterococcus, etc.. Once infective endocarditis occurs, it can worsen heart failure. At the same time, the redundant organisms fall off and lead to embolism.
3, heart failure: for late complications, is the main cause of death in rheumatic heart disease, the incidence of 50-70%. The main manifestation is cardiogenic cachexia, multi-organ dysfunction.
Diagnosis and differentiation
Ancillary tests
Doppler echocardiography : As a noninvasive method, it has been one of the main means to evaluate each valve lesion, not only to determine the size of the heart chambers and ventricular function, but also to measure the transvalvular pressure difference, valve opening area, pulmonary artery pressure and other indicators.
Radiography : It can understand the heart size and pulmonary changes.
Electrocardiogram : It can clarify the patient’s heart rhythm, the presence of myocardial ischemic changes, and whether there is a combination of atrial fibrillation, etc.
Cardiovascular angiography : For some patients older than 45 years old, the electrocardiogram suggests myocardial ischemic changes, and cardiovascular angiography examiners can clarify whether there is a combined coronary artery lesion.
Disease diagnosis
The diagnosis of rheumatic heart valve disease is relatively easy based on the patient’s medical history, clinical manifestations, physical signs, cardiac ultrasound and other examinations.
Differential diagnosis
Mainly infective endocarditis, valve lesions caused by congenital dysplasia, and age-related heart valve disease.
Surgical treatment
Indications for surgery
It should be noted that most patients with already severe hemodynamic valve disease should be treated surgically, even in the absence of clinical symptoms, unless there are combined contraindications to surgery. With advances in myocardial protection and cardiac surgery techniques, the outcome of rheumatic heart valve disease treatment has steadily improved, with a surgical success rate of 98% and satisfactory long-term survival rates, mainly for valvuloplasty and valve replacement.
Valvuloplasty
These include prosthetic annuloplasty alone or in combination, fibrous tissue stripping for leaflet thickening, leaflet excision patch repair for calcified foci, and correction of tendon thickening and fusion.
Valve Replacement
With the development of cardiovascular surgery technology and the improvement of people’s demand for quality of life, mitral valve replacement has gradually replaced closed mitral valve crossover separation, percutaneous mitral balloon dilatation, and direct vision mitral valvuloplasty junctional dissection as the main method of treatment for rheumatic heart valve disease at present.
Valve Selection
The two main types of prosthetic valves available today are biological and mechanical valves. Each valve has its own characteristics, and the cost of surgery does not differ much between the two valves. Patients can choose according to their situation.
First, for older patients over 65 years of age, a biologic valve is an option. The biologic valve eliminates the need for lifelong anticoagulants after surgery and avoids the complications associated with daily anticoagulants, making it a good option for younger women, especially those with pregnancy and childbirth needs. The average life expectancy of a bioprosthetic valve is about 10 years, which means that the valve may need to be replaced again after bioprosthetic surgery due to valve failure.
Mechanical valves are characterized by their longevity and resistance to wear and tear without concern for the decay and aging of the valve itself, but because of the destructive effect of mechanical valves on the blood, they have a tendency to form thrombi and require strict long-term postoperative anticoagulation with warfarin. Therefore, the choice of valve should take into account the patient’s age, the presence or absence of combined atrial fibrillation, and economic conditions.
Diet and Precautions
Diet: Pay attention to the postoperative period to strengthen nutrition, should not eat too salty food, mainly to supplement protein and various vitamins. Patients taking warfarin anticoagulation should not consume too much or long-term foods rich in vitamin K, such as spinach, pork liver, carrots, cauliflower, peas, etc. Since alcohol consumption can affect the metabolism of warfarin, do not drink alcohol during the anticoagulation period.
Medications: Some medications need to be taken on time in the early postoperative period, mainly anticoagulants, cardiac diuretics, etc. Replacement of the biological flap requires low-intensity anticoagulation therapy with aspirin for six months after surgery, while replacement of the mechanical flap requires lifelong anticoagulation medication.
Lifestyle habits: pay attention to maintain good lifestyle habits, stay up less and avoid straining.
Prevent infection: you can exercise properly to enhance your physical fitness and prevent respiratory inflammation such as cold, if you suffer from periodontitis, rupture, urinary tract infection, etc. You should seek medical attention promptly and take the initiative to explain to your doctor that you have undergone heart valve surgery and provide accurate information about your current medication.
Seek medical attention: Once you are unwell, you should use medication under the guidance of your doctor and not just use cold and flu medication and antibiotics on your own.
The results of a study by American physician Dabel concluded that the nicotine in tobacco is the bane of harm. After the nicotine enters the human bloodstream, it can lead to an increase in heart rate, blood pressure (excessive smoking can lower blood pressure), increased oxygen consumption of the heart, vascular spasm, abnormal blood flow and increased adhesion of platelets. In addition, smoking produces carbon monoxide, which binds to the hemoglobin molecule before oxygen, thereby reducing the ability of red blood cells to carry and deliver oxygen by about 20%.
Because of all these adverse effects, the incidence of coronary heart disease is three times higher in men between the ages of 30 and 49 who smoke than in non-smokers, and smoking is also an important cause of angina attacks and sudden death. In addition, smoking can lead to severe limb pain, known as “intermittent claudication” (vasculitis), which is the result of limb ischemia. The same lesion, if it occurs in the blood vessels of the brain, will cause stroke and hemiplegia.
Passive smoking and cardiovascular disease
Passive smoking can also increase the risk of cardiovascular disease. Our study suggests that passive smoking increases the risk of cardiovascular death (RR 1.37, 95% CI 1.06-1.78), also in children (RR 1.26, 95% CI 0.94-1.69). Another study from Hong Kong also found that the risk of coronary heart disease increased 1.6 times in women who were passive smokers, and the longer the duration of passive smoking, the higher the risk of coronary heart disease.
Currently, cardiovascular disease is one of the major killers of human beings. It is important to focus on prevention. It is not only the responsibility of the government to quit smoking, the whole population should be mobilized, and physicians should act as a living force to quit smoking. Especially in China, the incidence of cardiovascular disease is likely to remain on the rise in the coming decades, which will bring great harm to individual patients and society. The earlier smoking cessation begins, the more significant the cardiovascular disease benefits. Stay away from tobacco, health makes life better.