In the stenosis of the mitral hole there is an increase. Mitral stenosis of the heart valve: what it is, treatment, symptoms, reasons, signs

Etiology

1.Rumatic heart disease.

2.Aterosclerosis, calcine.

3. Basic endocarditis.

4. Thendocardites and holvulites with systemic collagencies.

5. Handraims of the heart.

6. Tumors of the heart.

ECG changes with acquired heart defects reflect hypertrophy, dilatation and overload of the corresponding heart chambers experiencing increased hemodynamic load. As a rule, with heart defects, there are sharply pronounced signs of increasing the departments of the heart, often with secondary changes in the myocardial of ventricles, a violation of the passage of the pulse along various departments of the conductive system.

Stenosis of the left car hole

In the presence of mitral stenosis, overload and an increase in left atrium with an increase in pressure in the pulmonary artery system and the progressive increase and overload of the right atrium and the right ventricle, which is reflected on the ECG:

1. By changing the teeth P, indicating an increase in the size of both atrial sservs - an increase and amplitude, and duration, often broadening dugorble teeth P (R-Mitrale).

2. EXCH Signs of the Hypertrophy of the right ventricle, often with signs of its overload (cososososisant shift of the ST segment and negative asymmetric Tuscom T in leads II, III, AVF, V 1 -V 2).

3. The most characteristic violation of the rhythm is the flickering of the atria (Fig. 172).

Mitral valve failure

In mitral insufficiency, the ECG records are recorded by signs of hypertrophy, dilatation and overloading of the left heads due to increasing the volume of blood passing through them:

1. EXCH MARKERS INCREASE OF THE LEFT SERVICE (Armed dugorble Teeth P - R-MITRALE).

2. References of left ventricular hypertrophy, often with violation of the processes of repolarization of hypertrophied myocardium (cosono-separating ST, and negative asymmetric teeth T in I, AVL, V 4 -V 6), Figure 173.

Combined mitral spill

1. How the rule is always determined by changing the atrial component by type R-MITRALE.

2. ECG signs of increasing both ventricles of the heart (Fig. 17).

Aortic Stenosis

The most pathognomonic for this heart disease is hypertrophy and expressed systolic overload of the left ventricle, which is reflected on the ECG:

1. The use of left ventricular hypertrophy with secondary changes in the myocardium in the form of the formation of cosososisant depression ST and negative asymmetric teeth T in I, AVL, V 4 -V 6.

2. The blockade of the left leg of the Gis beam is determined (Fig. 174).

Lack of aortic valve

For lack of valve apparatus, the aortic is characterized by volume (diastolic) overloading of the left ventricle, as a rule, without changes from the myocardium atrial. The following changes are noted on the ECG:

1. The use of the left ventricle hypertrophy unchanged by the end of the ventricular complex (negative teeth of T) are not formed, but with frequent formation of deep teeth Q in V 5, V 6.

2. In the development of the relative deficiency of the mitral valve - the formation of the R-Mitrale.

3. Sometimes the blockade of the left leg of the Gis beam is developing (Fig. 175).

Failure of the trilateral valve

The presence of isolated tricuspid failure leads to hypertrophy and dilatation of the right atrium and the right ventricle, the ECG is noted:

1. Increasing the increase in right atrium - the formation of P-Pulmonale.

2. EXCH Signs of the right ventricle hypertrophy (Fig. 176).

Stenosis of the right car holes

Isolated tricuspid stenosis - extremely rarely commonly acquired heart disease. The morphological substrate is an obstacle to the stream of blood from the right atrium into the right ventricle, leading to an increase in pressure in the cavity of the right atrium, its hypertrophy and dilatation. On ECG you can register:

1. Increasing the increase in the right atrium (R-Pulmonale).

2. Sometimes - low-contaminated signs of increasing the right ventricle (Fig. 177).

The frequency of mitral stenosis is 44-68% of all vices, develops mainly in women. It usually occurs as a result due to a long flowing rheumatic endocarditis; It is very rare it congenital or appears as a result of septic endocarditis. The narrowing of the left atreat and ventricular opening occurs during the battle of the flaps of the left atreservant-ventricular (mitral) valve, their seal and thickening, as well as during shortening and thickening tendon threads. As a result of these changes, the valve acquires a kind of funnel or a diaphragm with a slit hole in the middle. Less importance in the origin of the stenosis has a scarsing and inflammatory narrowing of the valve ring. With a long existence of the vice in the fabric of the affected valve, lime can be postponed.

Hemodynamics. In mitral stenosis, hemodynamics is significantly violated in the case of a significant narrowing of the atreservantic opening, when its cross section decreases from 4-6 cm 2 (normally) to 0.5-1 cm 2. During the diastole, the blood does not have time to move from the left atrium into the left ventricle, and in atriums there is some amount of blood, complemented by the influx of blood from the pulmonary veins. There is an overflow of the left atrium and the increase in pressure in it, which initially compensated for by the reinforced reduction in the atrium and its hypertrophy. However, myocardium left atrium is too weak to compensate for a pronounced narrowing of the mitral hole, therefore, its contractile ability decreases quite quickly, the atrium expands even more, the pressure in it becomes even higher. This entails an increase in pressure in the pulmonary veins, the reflex spasm of the small circle arteriole and the growth of pressure in the pulmonary artery, requiring greater work of the right ventricle. Over time, the right ventricle is hypertrophy (Figure 5). The left ventricle in mitral stenosis receives little blood, performs less than normal, work, so the dimensions are somewhat reduced.

Figure 5. Insurdic hemodynamics in normal conditions (a) and during the stenosis of the left atre-ventricular opening (b).

Diagnostics. If there are congestive phenomena in a small circle of blood circulation in patients, shortness of breath appear, heartbeat with physical exertion, sometimes pain in the heart, cough and hemoptia. During the inspection, acricyanosis is often noted; A blustery with a cyanotic tint (Fasies Mitrale). If a defect in childhood is developing, then there is often a lag in physical development, infantilism ("Mitral Nanism").

Some clinical signs of mitral stenosis:

Pulsus differens - appears when the left subcontractor artery appears in the left atrium.

Anisocoria is the result of the compression of the sympathetic barrel with an increased left atrium.

For examination of the heart areaa hearty impulse is often noticeable due to expansion and hypertrophy of the right ventricle. The top push is not strengthened with palpationin the region, it is detected by the so-called diastolic cat purring (presesting jitter), i.e. Low-frequency diastolic noise is determined.

Percussianfind the expansion of the heart dullness zone up and right at the expense of the left atrium hypertrophy and the right ventricle. The heart acquires a mitral configuration.

For ausclutation of the heartvery characteristic changes are found inherent in mitral stenosis. Since little blood gets into the left ventricle and it happens quickly, the ton of the top becomes loud, clapping. In the same time after the second tone, it is possible to listen to the addition of the discovery of the mitral valve. Loud i tone, II tone and the discovery of the mitral valve creates a typical melody for mitral stenosis, called quail rhythm. With an increase in pressure in a small circle of blood circulation, an emphasis of the second tone above the pulmonary barrel appears.

For mitral stenosis, a diastolic noise is characteristic, because there is a narrowing of blood flow from the left atrium into the ventricle during diastole. This noise may occur immediately after the discovery of the mitral valve, because due to the difference in pressure in the atrium and the ventricle, the rate of blood flow will be higher at the beginning of the diastole; As pressure leveling, the noise will decrease.

Often, the noise appears at the end of the diastole in front of the systole and pretensity noise, which occurs when the blood flow occurs at the end of the ventricular diastole due to the starting systole atrial systole. The diastolic noise in mitral stenosis can be heard over the entire diastole, amplifying in front of the systole and directly merging with the I clapping tone.

Pulsewith mitral stenosis, it may be unequal on the right and left hands. Since with a significant hypertrophy of the left atrium, the left plug-in artery is squeezed, the pulse filling on the left decreases (Pulsus differens). With a decrease in the filling of the left ventricle and reduce the shock volume of the pulse becomes small - Pulsus Parvus. Mitral stenosis is often complicated by flickering arrhythmia, in these cases, the pulse arrhythmic.

Arterial pressureit usually remains normal, sometimes systolic pressure is slightly low and the diastolic increases.

X-rayan increase in the left atrium characteristic of this vice is detected, which leads to the disappearance of the "waist" of the heart and the appearance of the mitral configuration. In the first oblique position, the increase in the left atrium is determined by the deviation of the esophagus, which is clearly visible when taking a patient of the susceptible barium sulfate . With the increase in pressure in a small circle of blood circulation, radiologically marks the emission of the pulmonary artery arc and hypertrophy of the right ventricle. Sometimes the reverence of the left atre-ventricular valve is detected on the radiograph. With prolonged hypertension of the blood circulation vessels, pneumosclerosis develops, which can also be revealed at a radiographic study.

ECGin mitral stenosis, reflects the left atrium hypertrophy and the right ventricle; The magnitude and duration of the PC, especially in I and II of the standard leads, the electric axis of the heart deflects to the right, the high tooth appears Rin the right breasts and pronounced teeth S. in left chest.

Ehochein mitral stenosis, a number of characteristic features take care (Figure 6):

Figure 6. Echocardiogram in the stenosis of the left atreservantic opening. Mitra valve flaps movement has a p-shaped.

GS - chest; SPA - the last wall of the right ventricle; PZ - right ventricle; MZHP - interventricular partition; Lz left ventricle; PSMK - the front sash of the mitral valve; ZSLZH- rear wall of the left ventricle; ZSMK is a sash of the mitral valve.

1. Peak A decreases sharply or disappears, reflecting the maximum opening of the left atrety-ventricular valve sash during the atrial systole.

2. The rate of the diastolic cover of the anterior flap of the valve is reduced, which leads to a decrease in the slope of the E-F interval.

3. Changes the movement of valve flaps. If in the norm of the sash during the diastology diverges in opposite sides (front sash - to the front wall, rear to the rear), then during the stenosis of the movement they become unidirectional, since due to the combature of the commissioner, a more massive front sash pulls back. The movement of the sash on EchoCG acquires a P-shaped configuration. In addition, with the help of ECCH, you can detect an increase in the left atrium, changing the valve flaps (fibrosis, calcification).

In case of mitral stenosis, the strokes in a small circle of blood circulation occurs early, which requires the enhanced work of the right ventricle. Therefore, the weakening of the contractile ability of the right ventricle and the venous stagnation in a large circulation circle is developing in mitral stenosis before and more often than with deficiency of the mitral valve. The weakening of myocardial myocardium of the right ventricle and its expansion is sometimes accompanied by the appearance of relative deficiency of the right atreat and ventricular (three-risk) valve. In addition, long-term venous stagnation in a small circle of blood circulation in mitral stenosis over time leads to sclerosis of vessels and the growth of connective tissue in the lungs. The second, pulmonary, barrier is being created to promote blood on the vessels of a small circle, which makes it difficult to work even the work of the right ventricle.

During the mitral stenosis, 3 periods are distinguished:

Compensation.

Pulmonary hypertension, hypertrophy of the right ventricle.

Of the right-hand deficiency (stagnation in a large circulation circle).

Complications of mitral stenosis:

Outragia left vehicle failure (cardiac asthma, lung edema).

Chronic cardiovascular failure (stagnation in the lungs).

Rhythm disorders (often atrial fibrillation).

Thromboembolic syndrome.

The addition of infectious endocarditis.

Insolvency of the prosthesis or displacement at commissionerotomy.

Eliminate 3 degrees of calcinosis MK:

Calcium is located in the free edges of the sash or in the commission of individual nodes;

Calcine sash without transition to fibrous ring;

The transition of calcium masses to the fibrous ring and the surrounding structures.

Differential diagnosis of mitral stenosis:

Mixoma heart (left atrium or ventricle).

Congenital defrost - Lutembash syndrome (stenosis of the mitral valve + DMPP).

Nonspecific Aorto Arteritis.

Treatment

Heart failure

At s \u003d 1.0-1.5 cm 2 restriction of heavy loads, and when<1.0 см 2 – только небольшие нагрузки.

Diuretics - with a stitch

Cardiac glycosides - with systolic dysfunction

IAPF carefully, because Vasodilators can reduce cardiac output

Surgical correction of vice

Valve prosthetics

Balloon valvaloplasty

Indications for balloon valvoplastics (ACC./ Aha., 2006)

Patients with moderate / pronounced stenosis (£ 1.5 cm2) and valve suitable for holvulotomy +

• Heart failure 2-4 FC.

  Without symptoms with pulmonary hypertension (\u003e 50 mm Hg) or recent atrial fibrillation.

  Cardiac insufficiency 3-4 FC with calcified valves and high risk of operation.

Indications for valve prosthetics

Patients who are not suitable for balloon holvulotomy +

• Cardiac insufficiency 3-4 FC with moderate or pronounced stenosis (£ 1.5 cm 2).

  Patients with pronounced stenosis (£ 1.0 cm 2), severe pulmonary hypertension (\u003e 60 mm Hg. Art.) And cardiac insufficiency of 1-2 FC.

Replacement of the valve with mechanical or biological, or xenoprosthesis.

Pulse Frequent, small filling and tension, in the early stages of the vice rhythmic. In later stages, single atrial extrasystoles appear first (this is detected on the electrocardiogram), and then due to the entire growing overvoltage of the left atrium, followed by a degenerative change in it, may occur paroxysmal tachycardia attacks or atrial fibries; In the future, a long-term fliccious arrhythmia is installed.

When appearance clear arrhythmia The presetative noise disappears, since the atrium is not reduced, but flicker. In connection with this form of arrhythmia, there is a deficiency of the pulse compared to the amount of heart abbreviations consistent with the hearing of the heart. This indicates a significant weakening of myocardial contractility.

Electrocardiogram It detects a significant predominance of the right ventricle, as well as high and in the future, the two-phase prong r. The Tuscom T reduced and deformed in cases where a significant dystrophic change in the myocardial of ventricles is occurring.
Venous pressure It rises very early and often reaches very large numbers. The rate of blood flow is slowed down (especially when determining the ethereal method).

Employment issues Patients with a narrowing of the left atreservantic opening should be carefully thought out, taking into account the severity of this disease and its rheumatic etiology.

ECG ECG Estimation Video Estimation for Hyperrophy and Stomats

Treatment of mitral stenosis

Treatment It has its own characteristics, since more often has to be resorted to the bloodsinking and use of oxygen therapy, mainly due to the enhancement of cyanosis and, sometimes the character of cardiac asthma. Often, leeches that facilitate pain are prescribed to the liver area.

DigitalisBy blocking the conductor system and suppressing the excitability of the sinus node, contributes to the transition of the tachycardic shape of fliccity arrhythmia in bradycardic. Therefore, for a long diastologist, the ventricle is well filled with blood and the contractility is restored: the pulse blows in frequency correspond to the amount of heart abbreviations, the pulse deficiency disappears, the blood circulation is restored.
In the rest of therapeutic activity correspond to those presented above and are appointed in relation to the stages of cardiovascular failure.

Patient R., 32 years. Suffered scarletin, diphtheria, articular rheumatism - three attacks; After the second attack (at the age of 24), a heart disease was detected, after the third (at 26 years old) -the 2 months in the Hospital with an increased temperature (Endocarditis Recurrens). In the future, recovered and worked, however, he felt short when lifting gravity. After 2 years (at the age of 28), after a hard work, hemloration and general weakness appeared. I lacquered 4 days in bed, then again started working. A year ago, the legs began to swell, pain in the right hypochondrium, frequent crosslinking, especially in a lying position, sometimes with a moocroty painted with blood.

Received In the clinic with complaints about strong shortness of breath and sinning in the chest. Objectively: bluish-red (falsely grinding) cheeks, bluish lips and fingertips. The heart is increased to the right and up; With radioscopy, a sharp protrusion of the left atrium is found; Heart diameter 5.5 + 7.5 cm. Auscultation: Mesoistolic noise with pre-primary amplification and clapping first tone in the top of the heart and several left it, split the second tone (rhythm quail) on the pulmonary artery. On the electrocardiogram (the same figure), an increase and splitting of the atrial teeth of P (asyligria of atrial activity) is noticeable. Pulse 90 beats per minute, rhythmic, weak filling. Arterial pressure 95/60 mm. The liver is enlarged, painful; ascites. Legs and lower abdomen, edema. Negative diuresis. The voice is hoarse. Largeoscopy: Pares left voice ligament.

After appointment natrestyanki, diuretina, theophylline, mercasal the patient's condition improved (lost 5 kg in weight); Ascites decreased, the spleen began to be tugged. The cough did not stop, a small amount of sputum was distinguished (in it - cells of heart defects). The patient was discharged after 4 months a water was appeared, frequent hem beams, and the patient died.

Conclusion. Rheumatic narrowing of the left atreservantic hole. The circulation violation, the overflow of the small circle, stretching the left atrium with the detached organs, was discovered. The patient came under observation already in the heart of the heartbeat of the liver and the deep violation of the contractile ability of myocardium.

- This is the narrowing of the area of \u200b\u200bthe left atrioventricular mouth, leading to the difficulty of the physiological current of the blood from the left atrium into the left ventricle. The clinically heart disease is manifested by increased fatigue, interruptions in the work of the heart, shortness of breath, coughing with hemoprod, discomfort in the chest. To identify pathology, auscultatory diagnosis, radiography, echocardiography, electrocardiography, phonocardiography, catheterization of heart chambers, atrio - and ventriculography are carried out. With pronounced stenosis, balloon holvaloplasty or mitral commissurotomy is shown.

MKB-10

I05.0.

General

acquired heart disease, characterized by a narrowing of the left atre-ventricular hole. In clinical cardiology, 0.05-0.08% of the population is diagnosed. The narrowing of the mitral hole can be isolated (40% of cases), combined with the lack of a mitral valve (combined mitral vice) or with the damage to other heart valves (mitral-aortic vice, mitral tricuspidal vice). Mitral vice is 2-3 times more often found in women, mainly aged 40-60 years.

Causes

In 80% of cases, the stenosis of the atrioventricular opening has rheumatic etiology. The debut of rheumatism, as a rule, occurs under the age of 20 years, and clinically pronounced mitral stenosis develops in 10-30 years. Among the less common causes leading to mitral stenosis are noted infectious endocarditis, atherosclerosis, syphilis, heart injuries.

Rare cases of mitral stenosis of irregular nature can be associated with severe calcine ring and mitral valve sash, a mixed left atrium, congenital heart defects (lyutembash syndrome), intracardiac blood closures. It is possible to develop mitralissance after commissioning or prosthetics of the mitral valve. The development of relative mitral stenosis may be accompanied by aortic insufficiency.

Pathogenesis

Normally, the area of \u200b\u200bthe mitral hole is 4-6 square meters. cm, and its narrowing to 2 square meters. cm and less accompanied by the appearance of intracardiac hemodynamics disorders. The stenosis of the atrioventricular hole prevents the height of blood from the left atrium into the ventricle. Under these conditions, compensatory mechanisms are included: the pressure in the atrium cavity increases from 5 to 20-25 mm Hg. Art., Left atrium systole is lengthening, the myocardial hypertrophy of the left atrium is developing, which, in aggregate, facilitates blood flow through a stenozded mitral hole. These mechanisms first allow you to compensate for the effect of mitral stenosis on intracardiac hemodynamics.

However, further progression of the vice and the growth of transmittral pressure gardener is accompanied by a retrograde increase in pressure in the system of pulmonary vessels, leading to the development of pulmonary hypertension. In conditions of significant lifting pressure in the pulmonary artery, the load on the right ventricle increases and the emptying of the right atrium is hampered, which causes the hypertrophy of the right heart departments.

Due to the need to overcome significant resistance in the pulmonary artery and the development of sclerotic and dystrophic changes in myocardium, the contractile function of the right ventricle decreases and its dilatation occurs. At the same time, the load on the right atrium increases, which ultimately leads to the decompensation of blood circulation in a large circle.

Classification

By area of \u200b\u200bnarrowing of the left atrioventricular hole, 4 degrees of mitral stenosis are distinguished:

• I degree - insignificant stenosis (hole area\u003e 3 sq. CM)
• II degree - moderate stenosis (opening area 2.3-2.9 square meters. cm)
• III degree - pronounced stenosis (opening area of \u200b\u200b1.7-2.2 square meters. cm)
• IV degree - Critical stenosis (opening area of \u200b\u200b1.0-1.6 square meters. cm)

In accordance with the progression of hemodynamic disorders, the course of mitral stenosis passes 5 stages:

• I.- Stage of full compensation for mitral stenosis to the left atrium. There are no subjective complaints, however, auscultatively identifies direct signs of stenosis.
• II. - Stage of circulatory disorders in a small circle. Subjective symptoms occur only during exercise.
• III - Stage of pronounced signs of stagnation in a small circle and initial signs of circulatory disorders in a large circle.
• IV.- Stage of pronounced signs of stagnation in a small and large circulation circle. Patients develop flickering arrhythmia.
• V. - Dystrophic stage, corresponds to the III stage of heart failure

Symptoms of mitral stenosis

The clinical signs of mitral stenosis, as a rule, occur at an atrioventricular opening area of \u200b\u200bless than 2 kV. See Increased fatigue, shortness of breath, during physical effort, and then alone, cough with the release of blood streaks in sputum, tachycardia, violation of the heart rhythm in the type of extrasystole and fliccity arrhythmia. With pronounced stenosis, ortopnoe occurs, night attacks of cardiac asthma, in more severe cases - the swelling of the lungs.

In the case of significant left atrial hypertrophy, there may be compression of a return nerve with the development of dysfony. About 10% of patients with stenosis of the mitral hole impose complaints of pain in the heart pain not related to physical activity. With a concomitant coronary atherosclerosis, stenocardia seizures are possible subcontocardial ischemia. Patients often suffer from repeated bronchitis, bronchopneumonia, brunt pneumonia. With a combination of stenosis with mitral insufficiency, bacterial endocarditis is often joined.

The appearance of patients with mitral stenosis is characterized by cyanosis of the lips, the tip of the nose and nails, the presence of limited bugs of the cheek ("Mitral blush" or "dummy"). Hypertrophy and dilatation of the right ventricle often determine the development of the heart hump.

As the rules in the abdomen, hepthegalia, peripheral edema, the swelling of the cervical veins, cavities (right-hand hydrotorax, ascites) appear. The main cause of death in the mitral vice is the thromboembolism of the pulmonary artery.

Diagnostics

When collecting information on the development of the disease, rheumatic history can be traced in 50-60% of patients with mitral stenosis. Palpation of the nastrordic region reveals the so-called "Cat purring" - a presets of a shroud, perforating the heart boundaries shifted up and right. The auscultation pattern is characterized by clapping I tone and the discovery of the mitral valve ("mitral click"), the presence of diastolic noise. Phonocardiography allows you to relate a listened noise with a phase of the cardiac cycle.

• Electrocardiographic examination. ECG reveals hypertrophy of the left atrium and right ventricle, heart rate disorders (flickering arrhythmia, extrasystolism, paroxysmal tachycardia, atrial flutter), blockade of the right leg of a beam of Gis.
• Ehoche. With the help of echocardiography, it is possible to detect a decrease in the area of \u200b\u200bthe mitral opening, sealing the walls of the mitral valve and the fibrous ring, an increase in the left atrium. Cleaning EchoCG in mitral stenosis is necessary to eliminate the vegetation and calcinosis of the valve, the presence of thrombas in the left atrium.
• Radiography. Data of radiological studies (chest radiographies, heart radiography with the contrastration of the esophagus) are characterized by swelling of the pulmonary artery arc, the left atrium and the right ventricle, the mitral configuration of the heart, the expansion of the shadows of hollow veins, the enhancement of the pulmonary pattern and other indirect signs of mitral stenosis.
• Invasive diagnostics. Under the probing of the heart cavities, an increased pressure in the left atrium and the right hearts of the heart is detected, an increase in the transmitral pressure gradient. Left ventriculography and atticness, as well as coronary angiography are shown to all applicants for the prosthetics of the mitral valve.

Treatment of mitral stenosis

Medical therapy is necessary in order to prevent infectious endocarditis (antibiotics), reduce the severity of heart failure (heart glycosides, diuretics), recruiting arrhythmias (beta blockers). In case of thromboembolis, the subcutaneous administration of heparin is prescribed under the control of the AFTT, the reception of antiagregants.

Pregnancy for women with mitral stenosis is not contraindicated if the area of \u200b\u200ban atrioventicular opening is more than 1.6 square meters. cm and there are no signs of cardiac decompensation; Otherwise, pregnancy is interrupted under medical testimony.

Operational treatment is carried out at the II, III, IV stages of hemodynamic disorders. In the absence of deformation of sash, ordinary, the damage to papillary muscles and chord is possible to perform balloon valvoplastics. In other cases, a closed or open commissioning is shown, during which the spikes dishes, the sash of the mitral valve are exempt from calcifications, thrombus from the left atrium are removed, cancellasty is produced in mitral insufficiency. Rough deformation of the valve apparatus is the basis for prosthetics of the mitral valve.

Prediction and prevention

Five-year survival with the natural course of mitral stenosis is 50%. Even a small asymptomatic vice is inclined to progression due to repeated attacks of rheumloard. Postoperative 5-year survival rate is 85-95%. Postoperative restenosis is developing approximately 30% of patients for 10 years, which requires mitral recomesumsurotomy.

The prevention of mitral stenosis is to carry out the anti-infliction prevention of rheumatism, the rehabilitation of chronic streptococcal infection. Patients are monitored by a cardiologist and a rheumatologist and the passage of regular complete clinical and instrumental examination to eliminate the progression of reducing the diameter of the mitral hole.

one). "Mitral" Tusk R - more than 0.12 C, dugorby in leads I, II, AVL, V 5, V 6. 2). Deep negative phase in allotment V 1. 3). With pulmonary hypertension - the deviation of the electrical axis of the heart to the right and the signs of the hypertrophy of the right ventricle (complexes of type R, RS, QR in the right infants and complexes of type RS, RS in the left chest leads).

Signs of hypertrophy of the right ventricle ECG: high tooth R. in right breasts and deep S B. left chest leads (attitude R: S. in the brand V1 greater than 1); deviation of the electrical axis of the heart to the right; reduction of the ST segment; Negative tooth T B. Right breastquations.

1. Clone of the electic axis of the heart to the right in combination with the depression of the ST segment and the change in the tissue T in II, III, AVF in the form of two-phase (+ -) or negativity

2. In the right breasts, the prong R (R / S is greater than 1.0) increases, and the tooth S (R / S is less than 1.0) increases in the left pectoons

Exam ticket number 4

1. Manifestations of exacerbation of chronic ischemic heart disease.

The exacerbation of IBS is manifested as angina. Clinic: pain syndrome - stressful pains arising from loads, stress, abundant meal, a duration of 1-15 min, compressive, grave, irradiating into the left hand, lower jaw; Related symptoms are nausea, vomiting, sweating, shortness of breath, fast fatigue, tachycardia, increased blood pressure. Market pallor, immobility. Laboratory data: ECG - depression of ST segment, appearance of ST Depression at heart rate more than 120, ventricular tachycardia. Myocardial infarction: pain lasting more than 15-20 minutes, not bought by nitroglycerin, shortness of breath (up to pulmonary edema), sweating, nausea, abdominal pain, dizziness, episodes of loss of consciousness, sharp decrease in blood pressure, arrhythmia, decreased heart rate up to 30-40. ECG signs: the appearance of new keys q width of more than 30 ms and a depth of more than 2 mm, the full blockade of the left leg of the Gis beam. Whey markers: KFK (MV-KFK), LDH, Mioglobin, Triponins.

2. Stigma alcoholism during liver cirrhosis.

Facies Alcoholica - a handful face, an extended venous network on the skin of the face, steaming, injection of blood vessels and conjunctiva; Teleangectas, "vascular stars", gynecomastia, palman erythema. Contracture Dupiitren, red nose.

3. Treatment of insulin-dependent diabetes mellitus.

Diet with lifting fat. Sugarizing drugs (increasing tissue sensitivity to insulin: manninyl, glurinorm). It is necessary to compensate for diabetes: normal glycemia during the day, elimination of gluclusuria, normalization of blood lipids. Diet. Isocalorial, 4-5 multiple, strictly distributed in the use of carbohydrates, the exclusion of carbohydrates, sufficient fiber, 40-50% of vegetable fats.60% of corner-24% fat-16% proteins, vitamins A, C, B1, B2, PP . Sugar substitutes - sorbitol, xylitis, aspartame. + Fitotherapy: peas, beans, arphazetin. Physical activity is contraindicated in retinopathy, nephropathy. Sugarpporting agents - sulfanimide. The amount of tissue insulin receptors increases the sensitivity to endogenous insulin, stimulates the activity of actually in cells, depress A-cells. 1 generation. Chlorpropamide, butamide, cyclamid is no more than 2 g / day, 2 generation. Glyibenklamide, glipisid.5-20 mg / day. Biguanides. Gibutid, Metformin. 2-3 Tab / day 0.5 g. Extrapacanatically acts. The effect on the receptor level is potent., Increase the permeability for glucose, increase the anaerobic glycoliz, increasing the utilization of its muscles, reduces the absorption of glucose to the intestine, reduces gluconeogenesis, increases glycogen., Activate lipolysis. .

4. Clinical and laboratory signs of nephritis activity.

Oliguria, proteinuria, renal hematuria, arterial hypertension (diastolic), swelling. Muscular cramps, renal eclampsia, OPN, nausea, vomiting.

5. ECG signs with an atrio-ventricular blockade.

I degree: lengthening interval P-R (P-Q) More than 200 ms due to the slowdown in the pulse through the AV-BED. Causes of AV-blockade I degree: an increase in the tone of the parasympathetic nervous system, the reception of drugs (cardiac glycosides, in-adrenoblockers, verapamil, diltiazem), lesions of the conductive system (fibrosis, myocarditis).

II degree: 1st type (Mobitz I,) Periodic is characterized Wetskebach -interlining interval P-R. From the heart cycle to the cycle, up to the termination of the pulse on the ventricles and the fallout complex QRS.Causes are the same. 2nd type (Mobitza Ii) is characterized by a sudden loss of the complex QRS. without preceding interval extension P-R.. The blockade usually occurs below the AV connections. Causes - myocardial infarction of the lower wall of the left ventricle, fibrosis conductive system of the heart (illness Leva) Surgical interventions on the heart. Usually tends to transition to AV-blocking III degree.

ILL Degree: no pulse on ventricles. Rhythm is set from the centers of the low order - ventricles. The frequency of ventricular cuts is usually 35-50 per minute. Dizziness and fainting are possible as a result of a deterioration in cerebral circulation (attacks Morgali-Adams - Stokes).

Blocade I degree in ECG in the form of an extension of the interval PQ. up to 0.21 s or more. In this case, the atrial impulses reach ventricles, the rhythm remains correct. The atrum-ventricular blockade of the II degree is characterized by the loss of individual ventricular complexes due to the fact that the impulse from the atria does not be carried out on the ventricles. 2 types of this blockade are distinguished: I type - type of WetCabach, the type of Mobitz I is characterized by the progressive lengthening of the interval PQ B. Row of 3-4 cycles. At the same time interval PQ. It can be lengthened from a normal 0.18 c to 0.21 s in the next cycle and then up to 0.27 s, while the next pulse is not carried out on the ventricles and the reduction falls out. Such an increase in interval PQ. Before losing the ventricular complex can be natural (periods of Westerbach). In the atrial stomach blockade of type II - type of Mobitz II lengthening interval PQ. Before losing the ventricular complex is not observed, and the loss can be both regular and irregular. If the atriavio-ventricular blockade is recorded with 2 "l,it is impossible to attribute it to one or another type.

The atrial stomach blockade of the III degree (complete atrial stomach blockade) is characterized by the fact that atrial pulses are not conducted, and ventricular activities are supported by a rhythm outgoing from the conductive system. Atrium and ventricles are excited at the same time in an independent rhythm from each other. The ECG detects teeth R after the same intervals and independently of them complexes QRST. (Highly rarely arising) in the right rhythm.

6. Pulmonary hypertension. Causes. Clinic. Instrumental research methods.

The increase in the average blood pressure in the light artery is more than 20 mm RT. Art. Alone and more than 30 mm Hg. Art. With load. Causes: Vices of the Mitral Valve, Left Surveillance Failure, Light Atroca Mixoma, Celebration of Light veins, open arterial duct, chronic alveolar hypoxia (chronic diseases of the lungs, stay in highlands), emphysema lungs, chronic destructive lung diseases. When the reason is not clarified - the primary light hypertension. Clinic: shortness of breath (present in peace, enhances with a minor physical activity, persists in the sitting position), fast fatigue, dry (unproductive) cough, pain in the chest (due to the expansion of the body of the light artery and myocardial ischemia of the right ventricle), the edema on Legs, pain in the right hypochondrium (due to the increase in the liver), the appearance of voice hoarse in patients with light hypertension due to the compression of a returnable gangneal nerve by an expanded light artery trunk, syncopal states during exercise, because Right ventricle is not capable of increasing the heart emission adequately needs to be increased during load. Inspection: cyanosis (peripheral vasodulation as a result of hypercaps, the patients are usually warm in the patients). Pulsation: in the taper area - hypertrophied right ventricle, in the II intercosta to the left of the sternum - the trunk of the light artery. The swelling of the cervical veins is on the breath and exhale. Peripheral edema and hepatomegaly. Auscultation: Systolic "Click" and accent Tone on a light artery, fixed splitting of Tone II, in 11 intercostal heels to the left of the saint systolic noise of expulsion, soft diastolic noise noise of the laid artery valve, systolic noise in the projection of the three-dimensional valve. X-ray: expansion of the trunk of the light artery and the roots of the lungs, expanding the right downward branch of the light artery more than 16-20 mm. ECG: P-Pulmonale (High Teeth R in leads II, III, AVF, VI), deviation of the electrical axis of the heart to the right, signs of hypertrophy of the right ventricle (high teeth R. In leads VI-Z and deep teeth S. In leads VS-E) "Signs of the blockade of the right leg of a fox beam. EchoCG: dilatation of PP and PJ, thickening of the PZ wall (more than 5-6 mm). Catheterization of heart cavities: increased pressure in the light artery, the pressure of the sloping of the light artery is low or normal.