علائم و علل نارسایی دریچه میترال قلب

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علائم و علل نارسایی دریچه میترال قلب

شکافتن دریچه ی میترال به وسیله بالون از علت بوجود آورنده نارسایی دریچه ی میترال می شود

 

نارسایی دریچه میترال (MR) (mitral regurgitation)

نارسایی دریچه میترال بین حفرات سمت چپ قلب یعنی دهلیز چپ و بطن چپ قرار دارد.  در نارسایی دریچه میترال، دریچه نمی تواند بخوبی بسته شود و در نتیجه خون دوباره به دهلیز برگشت می کند.

 

این وضعیت باعث می شود که فشار در ورید های ریوی که به  دهلیز چپ میریزند  بالا برود که موجب احتقان ریوی و تنگی نفس می شود.  همچنین بخاطر برگشت قسمتی از خون پمپ شده توسط بطن چپ به دهلیز چپ، سمت چپ قلب مجبور است که حجم  بیشتری خون  پمپ کند تا گردش خون بدن را تامین کند و در نهایت هم به علت فعالیت زیاد، نارسایی قلبی مزمن و تپش قلب و تنگی نفس   پدید می آید.

 

با بزرگ شدن دهلیز چپ، احتمال آریتمی های قلبی مثل AF نیز وجود دارد. گاهی بوی‍‍‍ژه در موارد درگیری روماتیسمی دریچه های  قلب، نارسایی میترال می تواند همراه با تنگی میترال همزمان دیده  شود.

 

معمولاً برای تأیید تشخیص نارسایی دریچه ی میترال از اکوکاردیوگرافی استفاده می شود

 

علایم نارسایی میترال :

علایم نارسایی مزمن میترال با پیشرفت تدریجی شدت بیماری، معمولا به تدریج و در عرض چند ماه یا چند سال ایجاد می شوند اما اگر علت ایجاد آن سکته قلبی و یا عفونت دریچه ای باشد ممکن است بطور ناگهانی نارسایی حاد میترال ایجاد شود .علایم نارسایی میترال عبارتند از :

 

◊  خستگی زودرس  نامعمول : به علت کاهش برون ده موثر قلبی.

 

  تنگی نفس در حین انجام فعالیت بدنی: به علت عدم افزایش کافی برون ده قلبی.

 

  طپش قلب (آگاهی از نامنظم و یا غیر طبیعی بودن ضربان های قلب ): به علت نارسایی قلبی یا آریتمی.

 

ادم ریه: تنگی نفس هم در هنگام فعالیت و هم در هنگام استراحت به علت جمع شدن مایع در ریه ها بعلت افزایش فشارخون  ریوی ایجاد شود.

 

ادم محیطی: با پیشرفت به نارسایی سمت راست قلب، تجمع مایع در بافتهای بدن منجر به ادم  مچ پاها می شود.

 

 تشخیص نارسایی دریچه ی میترال

 

علل نارسایی دریچه ی میترال

علل ایجاد نارسایی دریچه ی میترال اولیه میترال عبارتند از:

نارسایی دریچه ی میترال ناشی از استحاله میگزومی دریچه میترال (میگزوم myxoma، عبارت است از تورموی مرکب از سلول های بافت همبند ابتدایی و بافت پشتیبان شبیه به مزانشیم).

بیماری های ایسکمیک (ناشی از نرسید خون) قلب/ بیماری رگ های کرونر قلب از علل بوجود آورنده نارسایی دریچه ی میترال می باشند.

نارسایی دریچه ی میترال ناشی از بیماری کُلاژن رگها (لوپوس اریتماتوی سیستمیک، سندرم مارفان).

آندوکاردیت عفونی (التهاب پوشش درونی حفرات قلب) می تواند منجر به نارسایی دریچه ی میترال شود.

نارسایی دریچه ی میترال ناشی از بیماری روماتیسم قلبی و ضربه

شکافتن دریچه ی میترال (والوولوتومی میترال) به وسیله بالون (بادکنک مخصوص) از علت بوجود آورنده نارسایی دریچه ی میترال می شود.

بعضی داروها (مثل فن فلورامین) می توانند شرایط را برای نارسایی دریچه ی میترال فراهم آورند.

 

نارسایی دریچه میترال بین حفرات سمت چپ قلب یعنی دهلیز چپ و بطن چپ قرار دارد


نارسایی ثانوی دریچه ی میترال

نارسایی ثانوی دریچه ی میترال در اثر اتساع بطن چپ و در نتیجه،کشیده شدن حلقه دریچه ی  میترال و جابجایی عضلات پاپیلری ایجاد می شود. اتساع بطن می تواند در اثر هر عاملی که موجب کاردیومیوپاتی (بیماری عضله قلب) اتساعی شود (شامل نارسایی آئورت، کاردیومیوپاتی استاعی غیر ایسکمیک) به وجود آید.

 

نارسایی دریچه ی میترال شامل ۳ مرحله است که عبارتند از:

۱٫ نارسایی دریچه ی میترال مرحله حاد.

۲٫ نارسایی دریچه ی میترال مرحله مزمن جبران شده.

۳٫  نارسایی دریچه ی میترال مرحله مزمن جبران نشده.

 

۱٫ علائم نارسایی دریچه ی میترال حاد

علایم نارسایی دریچه ی میترال مرحله حاد عبارتند از علایم نارسایی احتقانی قلب جبران نشده قلب شامل تنگی نفس، ادم (تورم) ریوی، خستگی، تنگی نفس در وضعیت خوابیده، تنگی نفس حمله ای شبانه و نیز علایم نارسایی دریچه ی میترال ،وضعیت پایین بودن برون ده قلب (کاهش تحمل نسبت به ورزش و فعالیت بدنی) می باشد.

 

۲٫ علائم نارسایی دریچه ی میترال مزمن جبران شده

ممکن است کُلاپس (ناتوانی شدید) قلبی عروقی همراه با شوک (شوک قلبی) در افراد مبتلا به نارسایی دریچه ی میترال مزمن جبران شده، علایمی موجود نباشد و تحمل نسبت به ورزش و فعالیت بدنی، طبیعی باشد و شواهدی از نارسایی قلبی وجود نداشته باشد.

 

افراد مبتلا به نارسایی دریچه ی میترال مزمن جبران شده نسبت به تغییرات جزئی وضعیت حجم داخل عروق حساس هستند و استعداد بروز نارسایی احتقانی قلب در آنها وجود دارد. در نارسایی دریچه ی میترال مزمن جبران شده که تحت درمان قرار نگرفته است، علایم پرفشاری ریوی و نارسایی قلب راست ایجاد می شوند.

 

برای تشخیص نارسایی دریچه ی میترال از سمع صداهای قلبی و گرفتن نوار قلب استفاده می شود

 

مقایسه نارسایی دریچه میترال MR با تنگی دیچه میترال یا MS

بیماران دچار  MR نسبت به  MS دیرتر به علت مشکلشان به پزشک مراجعه می کنند چون در  MR تا وقتی  LV نارسا نشده بیمار علامتی ندارد.

 

شیوع سرفه ی خونی هموتیزی در MS بیشتر از MR است.

 

  شیوع آمبولی های سیستمیک در  MS بیشتر از  MRاست.

 

علائم ضعف و خستگی در MR مزمن نسبت به  MS بیشتر است (در  MS علائم ضعف و خستگی در انتهای بیماری مشاهده می شود در حالی که در  MR ضعف و خستگی به خاطرکاهش برون ده قلب آشکارتر است).

 

فیبریلاسیون دهلیزی  (AF) در مریض را به شدت بدحال می کند ( به علت تند شدن rate ) ولی در  MR تأثیر آن به این اندازه نیست.

 

ممکن است MR خفیف سالها در وضعیت بدون علامت باقی بماند، آنچه باعث تشدید MR می شود وقایعی مثل یک اندوکاردیت یا کنده شدن یک کورداتندینی است. بیماری مارفان سرعت پیشرفت  MR را بیشتر می کند.

 

عوارض نارسایی دریچه میترال
در نارسایی دریچه میترال، به علت اختلال در کار این بخش از قلب، دریچه کامل بسته نشده و خون دوباره به دهلیز باز می‌گردد. این وضعیت فشار را در رگ‌های منتهی به ریه که به دهلیز چپ می‌ریزند را افزایش می‌دهد و در ‌‌نهایت موجب احتقان ریوی و تنگی نفس می‌شود.

از دیگر عوارض نارسایی دریچه میترال را تضعیف بخشی از ماهیچه‌های قلبی دانست و علاوه بر این موضوع به خاطر برگشت قسمتی از خون پمپ شده توسط بطن چپ به دهلیز چپ، این بخش مجبور به فعالیت بیشتر برای پمپاژ کردن متناسب با نیاز بدن است.

 

در نتیجه به علت فعالیت بیش از حد استاندارد این امر باعث نارسایی‌های مزمن قلبی در بلند مدت نیز خواهد شد.

  

از اکاردیوگرافی از راه مری برای تعیین شدت نارسایی دریچه ی میترال استفاده می شود

 

تشخیص نارسایی دریچه ی میترال

برای تشخیص نارسایی دریچه ی میترال، از سمع صداهای قلبی و گرفتن نوار قلب (ECG) استفاده می شود که به عنوان مثال در نارسایی دریچه ی میترال دراز مدت علایم بزرگی دهلیز چپ و هیپرتروفی بطن چپ را نشان می دهد. در نارسایی مزمن دریچه میترال ممکن است علایم لرزش (فیبریلاسیون) دهلیزی نیز در ECG دیده شوند.

 

در نارسایی دریچه ی میترال حاد هیچ یک از این یافته ها در ECG وجود ندارند. اندازه گیری میزان نارسایی دریچه ی میترال معمولاً به وسیله اکوکاردیوگرافی یا MRI (آنژیوگرافی رزونانس مغناطیسی) قلب صورت می گیرد.

 

در رادیوگرافی قفسه سینه افراد مبتلا به نارسایی مزمن دریچه میترال، بزرگی دهلیز و بطن چپ دیده می شود. نشانه های عروق ریوی در افراد مبتلا به نارسایی دریچه ی میترال به طور معمول طبیعی هستند زیرا معمولاً فشارهای سیاهرگی ریوی به طور قابل ملاحظه افزایش نمی یابند.

 

معمولاً برای تأیید تشخیص نارسایی دریچه ی میترال از اکوکاردیوگرافی استفاده می شود. در داپلر رنگی اکوکاردیوگرام قفسه سینه (TTE) جت خونی که از بطن چپ به داخل دهلیز چپ در طول سیستول بطنی عبور می کند دیده می شود.

 

در بعضی موارد به دلیل آنکه نمی توان تصاویر دقیقی از دهلیز چپ و سیاهرگ های ریوی به وسیله ی TTE به دست آورد، از اکاردیوگرافی از راه مری برای تعیین شدت نارسایی دریچه ی میترال استفاده می شود.

  

علل نارسایی دریچه میترال قلب

 

درمان نارسایی میترال

¤ در بیمار دچار نارسایی مزمن میترال  (chronic MR) هر ۶  ماه تا یک سال بیمار را به وسیله اکو monitoring می کنیم و ۲ مورد زیر را مورد توجه قرار می دهیم:

–  کسر جهشی یا EF افت کرده است یا نه.

– دیلاتاسیون  LV یا گشاد شدن بطن چپ

 

¤ از لحاظ management باید پروفیلاکسی اندوکاردیت  (EI) در مواردی که لازم است انجام شود.

 

¤ در صورت وجود فیبریلاسیون دهلیزی  (AF) آنتی کوآگولان می دهیم.

 

¤ در صورت نارسایی قلب دیورتیک، دیگوکسین،  ACE inh ، هیدرالازین.

 

¤ برای کم کردن پس بار  (after load reduction) ACEinh مثل لوزارتان، کاپتوپریل، انالاپریل و کم کردن شدت پس بار  (after load) شدت  MR کم می شود.

 

¤ جراحی، باید قبل از نارسایی بطن چپ  LV انجام شود، در جراحی یا دریچه را تعویض می کنیم و یا ترمیم می کنیم. ترمیم دریچه در موارد پرولاپس میترال، پارگی پاپیلاری ماسل ها، پارگی کورداتندینی ها صورت می گردد.

 

¤ تعویض دریچه در  MR ناشی از تب روماتیسمی به خاطر دژنره شدن خیلی شدید دریچه و همچنین در کلسفیه شدن شدید دریچه صورت می گیرد.

 

راهی برای پیشگیری از بیماری نارسایی دریچه میترال وجود ندارد

 

چه موقع برای بیمار اقدامات درمانی انجام می دهیم؟

۱٫ در ابتدای  MR، EF حتی از حد نرمال هم بالاتر است (بیش از ۶۰٪)، اگر  EF به ۶۰ و زیر ۶۰ رسید نشان دهنده این است که  LV نارسا می شود (پس در بیمارانی که ۶۰ ≥ EF دارند)

 

۲٫ LV end systolic diameter باید کمتر از mm 45 باشد، در بیماران  MR این دیامتر شروع به افزایش می کند ( افزایش  ESD ) علامت دار بودن:
*  AF

* Pulmonary HTN


مثال: بیماری با  MR شدید و ۷۰٪ = EF و ۴۰ =  ESD مراجعه کرده اگر بیمار علامت دار بود باید جراحی کنیم و ربطی به ESD و  EF ندارد.

نکته : اگر امکان ترمیم دریچه وجود داشته باشد آستانه برای جراحی پایین می آید و باید زودتر جراحی را انجام دهیم اما در صورت نیاز به تعویض دریچه آستانه بالا می رود.

 

پیشگیری از نارسایی دریچه میترال

راهی برای پیشگیری از بیماری نارسایی دریچه میترال وجود ندارد. اما با در جریان قرار دادن پزشک متخصص و جراح قلب از یکی از مهم‌ترین عوارض نارسایی دریچه میترال یعنی عفونت دریچه میترال می‌تواند جلوگیری کرد.

 

گردآوری: بخش سلامت دخترونه

منابع:galb.ir

scipost.wikipg.com
 کتاب بیماری های قلبی

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