Rheumatism which owing to a chronic inflammation of all valve device leads to the progressing fibrosis and calcification with forming of tubular narrowing of the left atrioventricular opening as "a fish mouth" is a basic reason of a mitral stenosis.
Much less often the mitral stenosis is a consequence of atherosclerotic (idiopathic) calcification of the mitral valve. Casuistic seldom mitral stenosis develops owing to an infiltration or swelling of valve structures at a carcinoid syndrome, mukopolisakharidoza, an amyloidosis, a multiple myeloma and some other diseases. Cases of obstruction of the mitral valve by a myxoma, thrombosis of a spherical prosthesis are described.
Clinical picture of a mitral stenosis
At a moderate mitral stenosis of the complaint for many years can be absent. As a rule, the symptomatology appears at reduction of the area of a mitral orifice more than twice, i.e. less than 2 cm2. Most often fatigue at an exercise stress begins to disturb patients, an asthma — sometimes up to development of a picture of cardiac asthma.
At development of paroxysms of a ciliary arrhythmia patients show complaints to emergence of attacks of heartbeat. Less often the address to the doctor (as a rule, in the presence of a ciliary arrhythmia) is connected with thromboembolisms on a small and big circle of blood circulation. Progressing of a stenosis owing to increase of pulmonary hypertensia leads to emergence of night attacks of asthma, sometimes — to a fluid lungs and a pneumorrhagia. In certain cases the expressed dilatation of the left auricle leads to a prelum of a recurrent nerve and emergence of hoarseness of a voice (Ortner's symptom).
At a decompensation of defect and development of right ventricular insufficiency there are complaints to increase in stomach sizes, hypostases, in rare instances — on the pains of anginous character which are a consequence of subendocardial ischemia of a dilatirovanny right ventricle.
At physical inspection of the patient with a mitral stenosis cyanosis of lips, crimson and cyanotic coloring of cheeks (a mitral flush), arrhythmic pulse (ciliary arrhythmia) can come to light. The heavy mitral stenosis can be shown by a palpatorny phenomenon of diastolic trembling ("cat's purring"). The heart sizes mainly increase in the beginning at the expense of the left auricle up, and afterwards to the right at the expense of a right ventricle whereas the left border of heart remains normal.
The increased, clapping 1 tone and mitral click (mitral click) is characteristic of an auskultativny picture of a mitral stenosis. It is the additional, short-term, strong tone following at once the II tone not later than through 0,12 with, it chtoyavlyatsya important for its differentiation from the III tone. He is listened on a top and in Botkin's point.
Treatment of the patient with a mitral stenosis
The asymptomatic current does not demand prescription of medicines. In the presence of clinical manifestation fixed assets of conservative therapy are diuretics and beta-blockers. Purpose of vazodilatator as owing to impossibility of increase in cordial emission in response to decrease in peripheric resistance at patients the expressed arterial hypotension develops is undesirable, and reflex tachycardia because of shortening of a diastole worsens a krovenapolneniye of a left ventricle and increases stagnation of blood in the left auricle and a pulmonary artery. To all patients prevention of recurrence of rheumatism and infectious endocarditis is carried out.
The paroxysmal form of a ciliary arrhythmia, significant increase in sizes of the left auricle, thromboembolism in the anamnesis demand regular reception of indirect anticoagulants (warfarin). At episodes of a thromboembolism purpose of heparin in combination with aspirin, klopidogrely is shown. At a constant form of a ciliary arrhythmia treatment is carried out by the general principles.
Incubation of pregnancy is possible at the sufficient area of a mitral orifice (more than 1,5 cm2) and for lack of increase of heart failure, otherwise its interruption is shown. In exceptional cases, for example, at late terms, carrying out to pregnant women of balloon valvuloplasty and even a mitral commissurotomy is possible.
As the indication to surgical treatment serves reduction of the area of a mitral orifice less than 1,2 — 1,0 cm2, heavy pulmonary hypertensia — even at an asymptomatic current, and also existence recuring thromboembolisms.
Operation of the choice at young age at moderate deformation of shutters, preservation of their mobility, lack of calcification and the expressed defeat of chords and papillary muscles is balloon valvuloplasty, however it is contraindicated at mitral insufficiency, an infectious endocarditis, fibrinferment of the left auricle. In these cases of the most effective the open commissurotomy is considered — sometimes in combination with plastics of the mitral valve during which, along with an adhesiotomy, exempt shutters of the mitral valve from calcificats, delete blood clots from the left auricle and take in its ear, and with mitral insufficiency carry out a mitral annuloplasty. Nevertheless approximately the restenosis develops in 1/3 cases during 10 flyings after operation.
At rough deformation of the valve device, existence of right ventricular insufficiency, need of a tricuspid annuloplasty carry out prosthetics of the mitral valve.