Rheumatism, infectious endocarditis are the most frequent reasons of chronic mitral insufficiency, result calcification of a mitral ring, defeat of valves of heart at a system lupus erythematosus, a system scleroderma in it less often, and also aortoarteriit, degenerative diseases of connecting fabric — Marfan, Eylersa-Danlo's syndromes. Mitral insufficiency can arise as complication of balloon valvuloplasty.
Acute mitral insufficiency can develop as a result of a rupture of a chord at Marfan's syndrome, a gap or dysfunction of a papillary muscle at a myocardial infarction, at fast destruction or damage of shutters of the valve, for example, as a result of an infectious endocarditis, at an injury or surgical intervention (mitral valvuloplasty). As complication of prosthetics of the valve is possible development of also paravalvular regurgitation. The pathological processes leading to dilatation of cameras of heart — such as coronary heart disease, myocardial dystrophies, a cardiomyopathy, myocardites, can serve as the reason of relative mitral insufficiency.
Clinical picture of mitral insufficiency
Sudden development of symptoms of left ventricular heart failure with the phenomena of a fluid lungs and arterial hypotension is characteristic of acute mitral insufficiency; there are paroxysms of fibrillation of auricles; less often only the atrial ekstrasistoliya meets.
At chronic mitral insufficiency the symptomatology during 10 — 15 can be absent. Then there are complaints connected with heart failure: fatigue, an asthma at an exercise stress, and then — and at rest, heartbeat. Emergence of hoarseness of a voice owing to a prelum of a recurrent nerve the increased left auricle (Ortner's symptom) is possible. Further the complaints caused by the expressed stagnation in a small and big circle of blood circulation join: cough, pneumorrhagia, hypostases standing and other symptoms.
At survey cyanosis of lips can come to light. Pulse of average filling, at a decompensation — frequent. Perhaps tachypnea. The apical beat is displaced to the left, diffuse, strengthened; considerable mitral insufficiency sometimes is followed by emergence of systolic trembling in the field of a heart top. Expansion of border of heart to the left and down at the expense of a left ventricle and up — at the expense of the left auricle is characteristic.
For an auskultativny picture of mitral insufficiency the most characteristic is existence of the blowing, decreasing systolic noise with a maximum on a top (see the tab.) which is well carried out to the axillary area. Noise is better listened in position of the patient on the left side, amplifies after an exercise stress. Occasionally at the expressed pulmonary hypertensia systolic noise due to the lack of regurgitation can be absent. The I tone on a top is weakened. Lack of an interval between the I tone and systolic noise is typical that is well visible on the phonocardiogram. At heavy mitral insufficiency the top of heart has the III tone which is registered on the phonocardiogram through 0,12-0,18 from later II tone; diastolic noise — a consequence of a relative mitral stenosis can be listened.
The emphasis of the II tone on a pulmonary artery and occasionally disappearance of systolic noise because of the termination of regurgitation is a sign of pulmonary hypertensia.
Treatment of mitral insufficiency
Acute mitral insufficiency demands administration of diuretics (furosemide) and peripheral vazodilatator (Sodium nitroprussidum). For maintenance of a hemodynamics intra aortal balloon counterpulsation can be used.
The issue of surgical treatment is resolved taking into account weight of a condition of the patient and an etiology of mitral insufficiency. So, acute mitral insufficiency at an infectious endocarditis demands surgical intervention in the closest 24-48 h, and at a myocardial infarction conservative therapy with the further solution of a question of plastics of the mitral valve is more preferable.
Asymptomatic chronic mitral insufficiency — easy, moderate and even expressed, does not demand treatment. Pregnancy is transferred well. At any etiology of defect prevention of an infectious endocarditis is shown.
Emergence of symptomatology is the indication to surgical treatment. Operation of the choice is the plastics of the mitral valve as at it big synchronism of reductions of a left ventricle is reached, the risk of an infectious endocarditis is lower, continuous anticoagulating therapy is not required. However in the presence of calcificats, the expressed thickening of chords this operation is inapplicable. Then prosthetics of the mitral valve is carried out. At relative mitral insufficiency the annuloplasty can be used.