Non-rheumatic Mitral Regurgitation Heart Disease

Non-rheumatic Mitral Regurgitation Heart Disease

Non-rheumatic mitral valve regurgitation refers to the mitral valve itself and its surrounding anatomy such as left atrial, valvular dysfunction, tendon, papillary muscle and left ventricle. The cuspid regurgitation. There are many reasons for non-rheumatic mitral regurgitation. The more common of which are: mitral valve prolapse, papillary muscle dysfunction or chordae rupture, left atrial myxoma, valvular annulus calcification, congenital valvular malformation and infective heart Meningitis and so on. Depending on the degree of mitral regurgitation, the rate of progression and the existence time, it can cause different degrees of hemodynamic changes and clinical manifestations. Here are some of the more common non-rheumatic mitral regurgitation diseases.


Mitral Valve Prolapse Syndrome, Barlow’s Syndrome

Mitral valve prolapse syndrome, also known as Barlow syndrome, mitral valve murmur-murmur syndrome, refers to mitral valve prolapse to the left atrium when the left ventricle contracts, with or without mitral valve closure Incomplete, a series of symptoms and signs may appear clinically.


Causes and Pathological Anatomy of Mitral valve prolapse syndrome

This disease is a clinical syndrome that can be divided into two categories, primary and secondary, based on the cause. The cause of primary mitral valve prolapse is unknown, and some patients have a family history, which may be autosomal dominant hereditary disorders. The pathological anatomy is mainly mitral valve tissue myxoid degeneration, accompanied by excessive valve lengthening and relaxation. Can be seen in Marfan syndrome.

Secondary mitral valve prolapse can be seen in: coronary heart disease, congenital heart disease (secondary atrial septal ischemia) and so on. The clinical diagnosis of this disease is conventionally referred to as primary mitral valve prolapse. A mitral valve leaflet that is too long can protrude into the left atrium during systole of the left ventricle, forming a mitral valve prolapse, which can easily affect the mitral valve closure, with or without mitral regurgitation.


Clinical Manifestations of Mitral valve prolapse syndrome

1. Symptoms: Most patients are asymptomatic. The initial symptoms of some patients are fatigue, dizziness, and palpitations. Chest pain is more common, often episodic but similar to angina. The location of chest pain is variable and the duration varies, and the efficacy of nitrate drugs is uncertain. Heavier patients may experience dyspnea or syncope, and some patients have neuropsychiatric symptoms such as anxiety, mental disorders, and personality changes.


2. Signs: A typical cardiac listening clinic sees a non-spraying murmur in the middle and late apex of the apex area, which can be followed by a late systolic murmur, which is more clear in the left supine position. The rattle and its subsequent systolic murmur can exist separately. The presence of a karaoke alone indicates that there is only mitral valve prolapse, which is caused by the sudden stopping of the valve leaflet toward the atrial surface and the tension of the chordae. Coexisting systolic murmurs indicate mitral regurgitation. If mitral valve prolapse is associated with moderate to severe insufficiency, left ventricular hypertrophy and left ventricular dysfunction may be present. Arrhythmias are common. In addition, there may be abnormal chest, straight back, scoliosis and so on.


Laboratory and Other Inspections for Mitral valve prolapse syndrome

1. About 2/3 of the ECG patients have abnormal ECG, mainly ST segment and T wave abnormalities, Q-T interval is prolonged, u wave is obvious, atrial or ventricular arrhythmia, sinus node dysfunction and atrioventricular conduction resistance Wait.


2. X-ray examination: light heart is not large, those with severe mitral regurgitation may have left atrium and left ventricle enlargement, left ventricular angiography can clearly determine the number and location of prolapsed valves.


3. Echocardiography M-mode ultrasound showed that the mid-late stage of the mitral valve closure line (CD segment) was a hammock-like posterior process. Two-dimensional echocardiography showed that the anterior or posterior lobes of the mitral valve protruded to the left atrium, crossed the level of the mitral valve annulus, and the ultrasound Doppler examination, if accompanied by mitral regurgitation, can be measured on the left atrium The systolic turbulence spectrum was obtained. Two-dimensional color Doppler ultrasound mapping showed the mitral regurgitation, and the magnitude of the regurgitation was determined.


Diagnosis of Mitral valve prolapse syndrome

The presence of mitral valve rattle-systolic murmur is very helpful for diagnosis. Combined with echocardiography, the diagnosis can be confirmed, and left ventricular angiography can be performed for suspicious diagnosis.


Treatment of Mitral valve prolapse syndrome

Asymptomatic persons do not require treatment. Those with symptoms should be treated with acupuncture.

i. Arrhythmia may be the main cause of sudden death. For frequent ventricular premature beats and paroxysmal tachycardia, propranolol 30-60mg / day can be selected and taken orally in 3 times. Invalid feed can be amiodarone 0.4 – 0.6g / day, or quinidine 0.6 – 1.2g / day, divided into 3 times.

ii. Chest pain, those taking propranolol not effective, can change to nifedipine or verapamil.

iii. Prevent infective endocarditis, such as tooth extraction, surgery, skin infection, urinary tract infection, upper respiratory tract infection, etc. Use antibiotics for preventive treatment.

iv. Severe mitral insufficiency, valve replacement surgery is feasible.


Papillary Muscle Dysfunction (Insuficiency of the papillary Muscle)

Papillary muscle insufficiency refers to the ischemic, necrotic, fibrotic, or other causes of the papillary muscles attached to the atrioventricular valve chordae, causing contractile dysfunction, resulting in mitral valve insufficiency and mitral valve regurgitation.


Causes and Pathophysiology of Papillary muscle insufficiency

There are many causes of papillary muscle insufficiency, Burch’s etiology is classified as:

i. Papillary muscle ischemia.

ii. Left ventricle dilatation.

iii. Non-ischemic atrophy of the papillary muscles.

iv. Congenital abnormalities of the papillary muscle or chordae.

v. Endocardial disease (endocarditis, elastic fibrosis).

vi. Dilated or hypertrophic cardiomyopathy. Coordinated destruction of the papillary muscle contraction. Rupture of the papillary muscle or chordae. Papillary muscle dysfunction is more common in coronary heart disease, both acute myocardial ischemia (angina pectoris, myocardial infarction) and chronic myocardial interstitial fibrosis. Acute ischemia or necrosis of the papillary muscles causes partial contraction of the papillary muscles; the formation of ventricular wall tumors causes relative movement during the systole, causing the papillary muscles in the corresponding parts to pull the mitral valve leaflets toward the ventricle, and the papillary muscles break. Making the mitral valve leaflet lose its pulling force during ventricular systole and turning back to the left atrium will cause severe mitral regurgitation and severe mitral regurgitation.


Clinical Manifestations of Papillary muscle insufficiency

1. Symptoms: Mild symptoms may be asymptomatic, and papillary muscles may be damaged. Those with a large return flow may have palpitations, shortness of breath, and cough. Patients with acute ischemia of the papillary muscles or sudden rupture of the chordae tend to have a large number of mitral regurgitations, often with acute pulmonary edema and cardiogenic shock.


2. The signs apical systolic murmur is the most important sign of the disease. Papillary muscle dysfunction accompanied by angina pectoris, the vocal systolic noise of the apex changes with the onset of angina pectoris. The murmur of acute papillary muscle rupture has the characteristics of sudden full systole and rough, often accompanied by diastolic gallop or fourth heart sound.


Laboratory and Other Inspections for Papillary muscle insufficiency

1. The ECG may have ST-T changes, but there is no specificity. Anterior papillary muscle involvement is usually accompanied by anterior wall myocardial infarction. Therefore, ST-T changes appear in leads I, avl, v5, and v6. Posterior papillary muscle involvement is often associated with posterior and inferior myocardial infarction. ST-T changes are seen in leads II, III, and avF.


2. Two-dimensional echocardiography showed that the thickness and elasticity of the mitral valve leaflets were normal, the amplitude of leaflet movement was small, the valve mouth was small, the distance between the mitral valve and the ventricle was increased, and whether the chordae were broken The ultrasonic Doppler diagnostic instrument can detect the magnitude of the return flow.


3. X-ray examination often has left atrium, left ventricle enlargement, left ventricular angiography can be seen with mitral regurgitation.


Diagnosis of Papillary muscle insufficiency

The diagnosis of acute papillary muscle dysfunction is based on:

i.                  After the onset of acute myocardial infarction or severe angina pectoris, apex of grade III or more systolic phase is transmitted to the axilla.

ii.                The degree and nature of the systolic murmur (and systolic karaoke) are variable, and there can be S3 gallop and fourth heart sound.

iii.            After the use of isoamyl nitrite, the systolic murmur can be reduced; the squatting test can be enhanced.

iv.             Left ventricular angiography has the most diagnostic value, and echocardiography is also helpful.


Treatment of Papillary muscle insufficiency

I. Internal medicine treatment Treatment of the etiology, such as improving myocardial blood supply in patients with coronary heart disease, and measures to relieve angina pectoris are conducive to the recovery of acute papillary muscle dysfunction. Vasodilators can be used in patients with severe heart failure with reflux.


2. Surgical treatment of patellar papillary muscle rupture or chronic papillary tendon lesions with severe mitral valve regurgitation should be considered valve replacement or mitral annulus repair and papillary suture, with higher surgical mortality.


Calcification of Mitral valvular Ring

It is a kind of senile degenerative change. There is calcium deposits in the fibrous muscle ring of the mitral valve. In severe cases, it can cause mitral regurgitation.


Cause of Mitral Valvular Ring

The pathogenesis is not clear, it is more common in patients with existing atherosclerosis, and most often occurs in the ventricular surface of the posterior lobe. The incidence rate in the elderly population in European and American countries is about 0.5 to 10.0%. There is no exact data in China. With the popularity of echocardiography, it has been frequently found.


Clinical Manifestations of Mitral valvular Ring

Depends on the degree of flap calcification. Mild patients have no clinical manifestations: severely diseased annulus thickening and fixation, can not be reduced with ventricular contraction, mitral valve movement is limited, can cause mitral regurgitation or stenosis, and can be in the apical area and the lower left sternal border. Hear the systolic murmur to the bottom of the heart. Sinus node and conduction system degenerative changes coexist, and sinus bradycardia, atrioventricular block, slow ventricular atrial fibrillation, etc. are often present in this disease. A few patients form emboli due to annulus calcium looseness. Occurrence of embolism in different parts, more common is cerebral and retinal arterial embolism.


Diagnosis of Mitral valvular Ring

Mainly relying on X-ray and echocardiographic examination, X-ray chest radiograph can be found in the mitral valve annulus calcification. Two-dimensional echocardiography showed a strongly reflecting echo group in front of the atrioventricular junction. Move in the same direction as the left posterior ventricular wall.


Treatment of Mitral valvular Ring

Generally there is no obvious hemodynamic effect, but it can be left untreated and symptomatic treatment for those with heart failure symptoms.


Myxoma of the Heart

Myxoma of the heart is the most common primary tumor of the heart in clinical practice, mostly benign and rare. Myxomas can occur on the endocardial surface of all hearts, 95% in the atrium, about 75% in the left atrium, 20% in the right atrium, and 2.5% in the left and right ventricles. Myxomas of the left atrium often occur near the ovary fossa. Clinically, the mitral valve orifice is often blocked by tumors, resulting in stenosis or incomplete closure of the mitral valve orifice. Myxoma can occur at any age, but it is most common in middle age More common in women.


Pathology for Myxoma of the heart

Tumors vary in size and are often connected to the atrium or ventricular wall with various pedicles, with various shapes and shiny appearance, which are translucent jelly-like. The cut surface is substantial, with patchy bleeding areas and small cystic cavities filled with blood clots. It can be seen under the microscope that the tumor cells are star-shaped, spindle-shaped, round, or irregular, scattered or closed-closing and distributed in a large number of mucus-like stroma, and the nucleus is mostly mononuclear or multinuclear tumor giant cells. Myxar sarcoma cells have different morphology, large nucleus, deep staining, and nuclear division. The tumor cells can infiltrate into small blood vessels to form tumor plugs.


Clinical Manifestations of Myxoma of the heart

The clinical manifestations of this disease depend on the location, size, and nature of the tumor and the presence and length of the pedicle. Elderly with large tumor pedicles may easily cause atrioventricular valve stenosis or insufficiency, resulting in hemodynamic changes and a series of symptoms. Small tumor pedicles may be asymptomatic for a long time.


I. Symptoms of Myxoma of the heart

(I) Obstructive symptoms often include palpitations, shortness of breath, and decreased endurance of exercise. Left atrial myxomas such as obstructed pulmonary veins or mitral valve orifices can produce symptoms of pulmonary stasis that resemble mitral valve lesions; paroxysmal nocturnal breathing, hemoptysis Sputum, severe cases may have jugular venous distention, hepatomegaly and lower extremity edema. Myocardial tumors of the right atrium, such as obstructed vena cava and tricuspid valve, may show symptoms similar to pericardial effusions; jugular vein bloating, hepatomegaly, and edema. Obstructive symptoms of this disease are characterized by body position changes. If body-related vertigo and dyspnea occur, a sudden blockage of the atrioventricular valve caused by a tumor causes a significant decrease in stroke volume and sudden fainting or cardiac arrest may occur.


(2) Embolism: Fragments of myxomas or thrombosis on the surface of the tumor can cause systemic and pulmonary circulation embolism. Embolism occurs in about 40% of left atrial myxomas, and embolism is rare in right atrial myxomas.


(3) Systemic symptoms: fever, increased erythrocyte sedimentation, anemia, weight loss, and abnormal increase in serum α2 and β globulin, which may be related to hemorrhage and necrosis and inflammatory cell infiltration in the tumor.


II. Signs of Myxoma of the heart

(A) changes in heart sounds myxoma of the left atrium can appear:

i. First hypercardia in the apex.

ii. The second heart sound of the pulmonary valve is hyperthyroid and divided.

iii. In the lower left margin of the sternum, a flutter sound of early diastolic heart sounds can be heard, which can be transmitted to the apex and bottom of the heart, which suddenly stops after the tumor is pushed to the left ventricle. Caused by vibration of the ventricular wall or tumor pedicle.

In addition, a fourth heart sound can be heard in the anterior region of the heart.


(B) Cardiac murmur obstruction of the mitral valve and tricuspid valve can form mitral and tricuspid valve stenosis. When the tumor enters the ventricular cavity, insufficiency of the atrioventricular valve can occur. Incomplete closure may be the result of the tumor interfering with the valve closure, or it may be caused by repeated tumor contact with the valve, causing scarring on the valve, which resembles chronic rheumatic valvitis or even causes chordae rupture. By the diastole rumbling-like murmur, it is enhanced in the left supine position and weakened in the right supine position. Sometimes systolic murmurs (mitral regurgitation) can be heard depending on the position. In right atrial myxoma, systolic-diastolic friction-like murmurs can be heard in the 3-4 intercostal space on the left margin of the sternum. Left ventricular myxoma can be heard at the base of the heart and grade 3 jet systolic murmurs are transmitted to the neck, while right ventricular myxoma has grade 2-3 systolic murmurs in the 2-3 intercostal space of the left margin of the sternum.


Laboratory and Other Inspections for myxoma of heart

I. Test for anemia, blood clot, serum protein electrophoresis α2 and β globulin increased.


II. The electrocardiogram may have atrial and ventricular enlargement, I – II degree atrioventricular block, and incomplete right bundle branch block. Atrial fibrillation may also occur. In severe cases, there may be changes in ST-T.


III. X-ray patients with left atrial myxoma who have pulmonary stasis, prominent pulmonary artery segments, enlarged left atrium and right ventricle, and those with right atrial myxoma show widening of the superior vena cava shadow and enlarged right atrium and right ventricle.


IV. Echocardiography left atrial myxoma in the left ventricular cavity saw an abnormal spot patch light group, moving between the left atrium and left ventricle, the systole returned to the left atrial cavity, the diastole reached the mitral valve mouth Entering the left ventricle, the EF slope of the anterior mitral valve decreases and the left atrium increases. The right atrial myxoma has an abnormal reflected light mass in the right ventricle, the systole is in the right atrium, and the diastole moves with the tricuspid valve toward the right ventricle or enters the right ventricle through the tricuspid orifice. Right atrium and right ventricle increased.


V. Cardiovascular angiography Selective pulmonary angiography film or continuous filming, which can show the shadow of occupying filling defect in the left atrium, which indirectly confirms the tumor in the atrium. The right atrial myxoma is generally used for vena cava or right atrium angiography, and it can also show Occupant filling defect shadow in the room.


Diagnosis of Myxoma of the heart

Diagnosis basis:

i.                  Clinical characteristics; changes in obstruction symptoms, heart sounds and murmurs.

ii.               Echocardiography is currently the best method for diagnosing intracardiac myxoma, especially two-dimensional echocardiography can clearly show the outline and activity of the tumor.

iii.            Cardiovascular angiography shows space-occupying lesions in the heart cavity, but there are some false positives and own echocardiography, and cardiovascular angiography is rarely used.


Differential Diagnosis for Myxoma of the heart

Left atrial myxoma should be distinguished from mitral stenosis. Patients with mitral valve stenosis often have louder opening sounds, rarely fourth heart sounds, murmurs that do not change with body position, and no fluttering sounds. Suspects can be identified by echocardiography. The left atrial thrombus is also easily confused with left atrial myxoma. It can be seen in echocardiography that most of the left atrial thrombus appears in the posterior wall of the left atrium. Its abnormal reflected light mass lacks the characteristics of rapid movement with the cardiac cycle. Left atrial thrombus is often accompanied by mitral stenosis, reflex patterns of abnormal mitral valve activity can also be seen.


Right atrial myxoma should be distinguished from constrictive pericarditis, tricuspid valve stenosis, pulmonary valve stenosis, 3rd to 4th intercostal contraction, diastolic friction-like back and forth murmurs on the left margin of the sternum, symptoms, murmurs and changes in posture Has differential diagnostic value.


Treatment of Myxoma of the heart

The disease is at risk of sudden death, so suspicious patients should be diagnosed as soon as possible. After the diagnosis is clear, cardiac tumor resection can be performed as soon as possible to obtain better results.



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