Dispensary observation of children with congenital heart defects. Clinical examination of patients with heart disease

In most cases, in the second half of the first year of life. According to many authors, by the age of 1 year, the foramen ovale closes in only 50-60% of children. It is believed that it can spontaneously close throughout the life of an adult. In place of the closed oval window there remains an oval fossa in the form of a recess, occupying up to 28% of the area interatrial septum in the middle part. In cases of non-closure of the embryonic opening, an open oval window is detected, which is found according to the data various authors in 17-35% of adults.

The fundamental anatomical difference between secondary ASD is that with ASD there is organic defect - the absence of a greater or lesser part of the septum / minus the tissue, while in case of non-closure of the atrial valve / valve / or insufficiency of the valve foramen ovale. At the same time, the presence of a leaflet does not guarantee the reliability of the obturator function and, in some cases, may be accompanied by an antivalvular flow.

It is believed that in most cases it is practically asymptomatic and it is difficult to isolate any of its specific clinical manifestations. Patients may experience transient cyanosis due to an acute increase in pulmonary vascular resistance during a cry or prolonged breath holding.

There is no physical evidence for PFO if there are no concomitant CHD. However, be suspected in patients with transient generalized cyanosis.

A moderate left-to-right shunt is accompanied by physical findings that are noted in secondary ASD. These findings include a fixed split second heart sound, pulmonary systolic murmur exile.

Literature data demonstrate an ambiguous approach to the assessment clinical role small anomaly. More recently, the point of view about the practical harmlessness of PFO has steadily prevailed, considering it as a variant of the norm for the development of the interatrial septum. This point of view still exists in the works of some domestic authors, who believe that this defect does not cause hemodynamic disturbances and does not require surgical correction. However, along with recognition as a practically insignificant anomaly, there are facts indicating the possibility of serious life-threatening complications against its background. First of all, this concerns the problem of paradoxical embolism and hypoxemic conditions. They are caused by the activation of pathological blood flows through the interatrial opening. In such cases, function as an atrial septal defect. The main reason for this is called the insolvency of the valve of the oval window and the appearance of a “valve-inadequate” LLC, which occurs as a result of stretching of the interatrial septum (with atrial dilatation).

The combination of manifestations of disembryogenesis is natural. This applies to aneurysm of the interatrial septum. At present, aneurysm of the interatrial septum is regarded as a combined factor of embolization in patients with PFO.

Diagnosis: EchoCG - a gap is detected in the middle part of the MPP, due to LLC. Color Doppler sonography confirms a left-to-right shunt through a PFO.

Differential diagnosis: ASD (primary, secondary, in the area of ​​the coronary sinus), total anomalous pulmonary venous drainage

Management tactics for PFO detection: Children with a small shunt through need some kind of treatment. Oxygen therapy is indicated for children who develop transient cyanosis, as well as for patients with a right-to-left shunt through pulmonary hypertension.

The activity of children is not limited, except for patients with PFO who develop cyanosis during exercise.

Children with transient central cyanosis are under observation. They are shown conducting transcatheter occlusion of the OOO.

Complications: transient cyanosis, systemic paradoxical embolism, cerebral stroke due to paradoxical embolism.

OOO 2-4 mm, without reset, and also in the absence of dilatation of the right chambers of the heart and pulmonary hypertension is not a congenital heart disease.

Open ductus arteriosus

Frequency. PDA occurs in 5-10% of all children with CHD, except for preterm infants in whom PDA is a common problem. In children with a birth weight of less than 1750 grams, the presence of a persistent ductus arteriosus is determined in 45%, with a body weight of less than 1200 grams - in 80%.

Pathoanatomy. The ductus is usually a normal intrauterine vessel connecting the pulmonary artery trunk and the descending aorta, usually 5-10 mm distal to the orifice of the left aorta. subclavian artery. The duct usually has a narrower opening in the pulmonary artery. The size and shape of the duct vary widely.

Clinical manifestations. Patients with a small PDA usually do not have symptoms. With a large PDA, signs of heart failure are characteristic: poor weight gain, shortness of breath and tachycardia, frequent respiratory infections, pneumonia.

Physical research. In patients with a large PDA and a significant left-right shunt, hyperreactivity and an increase in the size of the heart on palpation are determined. Systolic murmur is determined along the left edge of the sternum. The pulsation of the arteries in the extremities may be increased due to a decrease in diastolic pressure. II tone is normal, however, with an increase in pressure in the pulmonary artery, its accent is determined. Medium-sized PDA is characterized by continuous systole-diastolic murmur.

Echocardiography. Allows visualization of the PDA in most patients. Doppler study helps to determine the hemodynamic situation, the direction of the shunt and the pressure gradient.

Figure 3. Schematic of the PDA.

Forecast. Spontaneous closure of the PDA may be delayed in a healthy newborn but is rarely seen after 1 month of age. With a large shunt, heart failure develops, repeated pneumonias, which can lead to death at an early age. The presence of a PDA premature newborn in combination with the immaturity of the lung parenchyma often leads to heart failure, bronchopulmonary dysplasia, dependence on mechanical ventilation. In the absence of treatment (medical or surgical) aimed at closing the PDA, such conditions are accompanied by high mortality.

Treatment. Indomethacin is used to close the PDA in preterm infants. The introduction of indomethacin is not effective in full-term newborns. The presence of a PDA, regardless of size, is an indication for its surgical closure.

Coarctation of the aorta

Frequency. constriction thoracic aorta in the isthmus (immediately distal to the origin of the left subclavian artery) occurs in 10% of all CHD. CA is more often described in males. Bicuspid aortic valve occurs in 2/3 of patients with CA. VSD accompanies CA in 50% of cases. CA is also a component of other complex heart defects, in the pathophysiology of which there is an increase in pulmonary blood flow.

Anatomy and physiology. When the aorta narrows below the isthmus, the ductus arteriosus continues to supply blood to the descending aorta after birth (fetal circulation persists). As soon as the pressure in the pulmonary artery begins to decrease, the blood circulation of organs and tissues below the diaphragm deteriorates sharply, up to the development of anuria, acidosis and death. Early surgical correction allows to restore the patency of the aorta. As an emergency resuscitation measure, intravenous administration prostaglandin E 1, which allows you to maintain the patency of the arterial duct for as long as you like. In the event that the narrowing of the aorta is moderate, the child experiences a natural closure of the arterial duct. In this case, as a rule, a network of collateral vessels develops, connecting the aortic arch with the descending aorta below the coarctation. Despite collaterals, pressure in the aorta before coarctation becomes higher than normal, and below the site of coarctation, it becomes lower than normal. Hypertension in the hands can be expressed already in the first months of life, and the function of the left ventricle is often disturbed.

Figure 4. Scheme of coarctation of the aorta.

Clinical manifestations. In newborns, the first clinical manifestation may be anuria, acidosis, and circular collapse with satisfactory or reduced pressure in the arms and the absence of pulse and blood pressure in the legs. At an older age, the difference in blood pressure and pulsation of the arteries of the upper and lower half of the body is also characteristic.

Auscultatory data are scarce. Systolic murmur is easiest to hear on the back in the interscapular region. With developed collateral circulation, noise can be heard over the entire chest.

echocardiography in small patients allows an accurate diagnosis. Visualization of the aortic isthmus in older children is more difficult.

Treatment. Surgical treatment is indicated at any age when the diagnosis is established, usually in the first months of life. The operation consists in resection of the narrowed area, with restoration of the aortic lumen by end-to-end anastomosis from the left-sided lateral thoracotomy. In 5-10% of patients there is a recurrence of coarctation after surgical treatment. The procedure of choice for these patients is balloon dilatation of the narrowed segment.

Tetralogy of Fallot

Frequency. TF is observed in 10% of all children with CHD. This is the most common cyanotic malformation observed after the first year of life.

Pathoanatomy. The original description of TF as a combination of four features (right ventricular outflow tract stenosis, VSD, aortic dextroposition, right ventricular myocardial hypertrophy) has been reduced to two main components: VSD and right ventricular outflow tract stenosis. VSD in TF is large, non-restrictive, occupies the entire subaortic region, usually equal to or greater than the diameter of the aorta. In 3% of cases, multiple VSDs are observed. Obstruction of the exit from the right ventricle is observed in 75% of patients at the level of the outflow tract. In 30% of children, stenosis of the pulmonary artery valve joins it. Only in 10% of patients the stenosis is limited only to the pulmonary valve.

Clinical manifestations. Systolic murmur is heard immediately after birth. Most patients have cyanosis immediately after birth. Shortness of breath on exertion, hypoxic attacks develop later in children with moderate cyanosis. Heart failure is not typical. Children at an early age with acyano- tic TF may be asymptomatic or may have signs of heart failure due to a left-to-right shunt.

Figure 5. Diagram of Fallot's tetrad.

Physical research. 1. Clinical manifestations depend on the degree of right ventricular outflow tract obstruction. The lower the pulmonary blood flow, the more pronounced hypoxia. The most typical blood oxygen saturation is about 70-75%. Visible cyanosis depends on two factors: the degree of hypoxia and the content of hemoglobin. The higher the hemoglobin, the earlier cyanosis is noticeable.

2. An intense systolic murmur is heard along the left edge of the sternum. The more pronounced the obstruction of the right ventricular outflow tract, the shorter and weaker the murmur. The second tone can be unsplit (because there is no pulmonary component) and accentuated (due to the increase in size and dextroposition of the aorta). In patients with pulmonary atresia, constant systole can be heard. diastolic murmur PDA or large aorto-pulmonary collateral vessels. Long-term cyanosis leads to characteristic changes nail phalanges fingers (drumsticks).

Echocardiography. Two-dimensional echocardiography and Doppler imaging may be sufficient to make a diagnosis and determine a treatment plan.

Forecast. Children with TF gradually become more cyanotic. Hypoxic seizures can develop in children early age(usually at the age of 2-4 months) and can lead to neurological damage and death. Developmental delay is observed in cases of severe cyanosis. Perhaps the development of thromboembolic complications and brain abscesses. Septic endocarditis is one possible complication.

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Figure 6. Scheme of TMS.

Strengthening of the I tone and diastolic murmur at the apex are due to increased blood flow through the mitral valve.

X-ray examination: the pulmonary pattern is enhanced, the cardiac shadow has the shape of an "egg" lying on its side, the heart is enlarged in size due to both ventricles, the vascular bundle is narrow in the anteroposterior projection and expanded in the lateral projection.

ECG: EOS deviation to the right, hypertrophy of the right atrium and right ventricle, left ventricular hypertrophy in the presence of VSD.

FKG: confirms auscultation data. There is no murmur or a VSD systolic murmur is recorded.

ECHOCG: origin of the aorta from the right ventricle, the pulmonary artery from the left, the location of the aorta in front and to the right of the pulmonary artery, visualization of the VSD, ASD or PDA.

Probing of the cavities of the heart: decrease in blood oxygen saturation in the peripheral arteries, aortic discharge from the right, and pulmonary artery from the left ventricle, increased pressure in the left ventricle with VSD or LA stenosis.

The course of the disease. According to many authors, 28% of children born with complete TMS die in the first week of life, 52% - in the first month of life, 89% - by the end of the first year, 7% - under the age of 5 years, 2% - up to 10 years. The causes of death in non-operated patients are: severe hypoxemia, heart failure, concomitant diseases (pneumonia, SARS, sepsis).

Treatment of patients with TMS is only surgical and, if possible, it should be early. To date, more than 50 methods of surgical treatment have been proposed, which are divided into two main types: palliative and corrective.

Newborns in critical condition, a closed balloon or knife atrioseptotomy is performed, which allows them to prolong their life. Others palliative operations are excision of the interatrial septum, systemic-pulmonary anastomoses in TMS with LA stenosis.

A radical correction under IR conditions is in the direction venous blood with a patch from the vena cava into the left ventricle, from which the pulmonary artery departs (intra-atrial correction). Also applies displacement main arteries with simultaneous transplantation of the mouths of the coronary arteries into the base of the pulmonary trunk. Operational mortality in radical correction defect is 15-20%.

Corrected TMS is less common. It accounts for 1-1.4% of all congenital heart defects. With this defect, the aorta departs from the anatomically right ventricle, which receives blood from the left atrium, into which the pulmonary veins flow. The pulmonary artery arises from the anatomically left ventricle, which receives blood from the right atrium, into which the vena cava flows. By itself, corrected TMS does not cause hemodynamic disturbances, since arterial blood enters the large circle, and venous blood enters the small circle.

DISPENSERIZATION AND REHABILITATION OF CHILDREN WITH CHD

Principles of organization of care for newborns with congenital heart disease:

1) timely detection of children with suspected CHD in the maternity hospital;

2) topical diagnosis of the defect;

4) timely surgical treatment.

All children with suspected congenital heart disease should be examined by a cardiologist, referred to a specialized hospital and then to cardiology centers to establish a topical diagnosis of the defect. During examination in a hospital (general clinical examination, ECG, FCG, radiography in three projections, echocardiography with dopplerography, measurement of blood pressure in the upper and lower limbs, exercise tests and pharmacological tests) a detailed diagnosis should be made indicating the topic of CHD, the degree of pulmonary hypertension, the phase of the course of the defect, the functional class, the degree of heart failure, the nature of complications and concomitant diseases. In all cases of congenital heart disease, a consultation with a cardiac surgeon is necessary to resolve the issue of indications and timing of surgical correction of the defect.

If there are signs of circulatory disorders, drug cardiotonic, cardiotrophic and restorative therapy is carried out. Patients with HF 1-2st need only cardiotrophic and general strengthening therapy (treatment of dystrophy, anemia, hypovitaminosis, immunocorrection). Patients with HF 3-4 st after active cardiotonic and diuretic therapy (except for patients with TF, hypertrophic subaortic stenosis) and treatment with vasodilators (ACE inhibitors) are discharged under outpatient supervision by a cardiologist and pediatrician. They are recommended prolonged treatment with maintenance doses of cardiac glycosides, ACE inhibitors, potassium and magnesium preparations, cardiotrophics.

Patients with CHD are discharged from the hospital (with the timing of the next planned hospitalization) under outpatient supervision by a cardiologist and pediatrician.

Children of the first month of life with CHD are observed by a cardiologist weekly, in the first half of the year - 2 times a month, in the second - monthly, after the first year of life - 2 times a year. At least once a year, and sometimes more often, the patient should be routinely examined in a hospital, including being examined by a cardiac surgeon, for dynamic control, dose adjustment of maintenance therapy, sanitation of foci of infection. At the same time, it is necessary to record an ECG at least once a quarter, conduct an echocardiogram 2 times a year and a chest x-ray once a year.

Existing opinion about a significant limitation motor activity patients with CHD in last years considered incorrect. Physical inactivity only worsens the functional state of the myocardium, especially against the background of the natural, age-related physical activity of the child's body. Taking into account the characteristics of each CHD, it is necessary to conduct regular exercise therapy classes according to a lightweight program, courses of therapeutic massage, tempering procedures.

Preventive vaccinations contraindicated in complex cyanotic malformations or CHD of the pale type with heart failure of 3-4 functional classes, as well as in the presence of signs of a current subacute bacterial endocarditis.

Psychological rehabilitation.

Patients with cyanotic heart disease occurring with thickening of the blood, impaired rheology, polycythemia, for prevention of possible thrombosis, especially in the hot seasons of the year, should consume a sufficient amount of fluid, as well as take anticoagulants and antiplatelet agents (curantyl, phenylin) in small doses.

Sanitation of chronic foci of infection(consultation of a dentist and an otolaryngologist 2 times a year).

The radical elimination of the defect has a significant positive effect on the functional state of the body. Children begin to gain weight, they have significantly reduced signs of circulatory disorders, their motor activity increases, and the tendency to recurrent respiratory diseases and the likelihood of developing bacterial endocarditis.

To prevent the development of infective endocarditis, it is necessary to isolate risk groups for IE, which includes:

All patients with CHD, especially with cyanotic CHD (TF, TMS with pulmonary stenosis), with aortic stenosis, bicuspid aortic valve, CA, small defects in the IVS;

Patients with auscultatory form of MVP;

All patients operated on for congenital heart disease, especially those with synthetic patches;

Patients with CHD who underwent catheterization of the heart cavities and great vessels, sewing in of pacemakers;

Patients with congenital heart disease, who, as a result of the operation, have valve prostheses installed;

Patients cured of infective endocarditis.

Particularly threatened by the occurrence of IE are patients with operated CHD in the first 2-6 months. after surgery, with weakened immunity, festering wounds, a tendency to pyoderma and furunculosis, as well as chronic foci of infection.

Primary prevention IE in all children with CHD and auscultatory form of MVP includes:

Ñ clinical examination by a cardiologist with a planned quarterly examination (general blood and urine tests, blood pressure, ECG), echocardiography - 2 times a year, chest x-ray 1 time per year. Consultation of a dentist and an otolaryngologist - 2 times a year.

Ñ when layering intercurrent diseases (ARVI, tonsillitis, bronchitis, etc.), it is necessary to carry out antibiotic therapy (penicillins, macrolides orally or intramuscularly for 10 days).

Ñ chronic foci of infection should be sanitized with a simultaneous full course of conservative treatment.

Ñ minor surgical operations (tonsillectomy, adenectomy, extraction of teeth, filling teeth of the lower gum level, surgical treatment of boils and other surgical procedures, as well as the installation of venous catheters, hemodialysis, plasmapheresis) and other interventions that can cause short-term bacteremia should be carried out strictly according to indications and under the cover of antibiotics). Antibiotics (semi-synthetic penicillins or macrolides) are prescribed 1-2 days before surgery and within 3 days after it.

After heart surgery, especially in the first 2 - 6 months, it is necessary to conduct daily thermometry. A general blood and urine test is performed during the first month after the operation every 10 days, during the first half of the year - 2 times a month, and during the second half of the year - monthly. Registration of ECG, EchoCG in the first half of the year is carried out quarterly, and then 2 times a year, chest x-ray 1 time per year. After discharge from the surgical cardiac center, the child is sent for examination to the hospital of the cardiology department after 3 months to consolidate the effect, conduct an examination, a course of immunomodulatory, cardiotrophic and vitamin therapy, and exercise therapy.

Particular attention should be paid to the “frozen” curve of weight dynamics, the periodic appearance of low-grade fever in operated patients, pallor, increased sweating, decreased exercise tolerance, increased “old” and the appearance of new heart murmurs, increasing anemization, periodic increase in ESR, moderate leukocyte neutrophilia, dysproteinemia, changes in urine tests. In such cases, it is necessary to perform repeated 2-3 single blood cultures for flora, examination and treatment in a hospital.

Spa treatment it is recommended to carry out in the conditions of local cardio-rheumatological sanatoriums. It is shown annually to patients with CHD for 60-120 days a year, before and after surgery. Contraindications to the stay of children in a sanatorium: severe circulatory disorders, heart failure of 3-4 functional classes, signs of current subacute bacterial endocarditis, a period of less than three weeks after an intercurrent disease and a year after surgery.

Children are not removed from the dispensary registration and are transferred under the supervision of a therapist. Careful outpatient dispensary control helps prevent the occurrence or progression of complications in children with congenital heart disease in the pre and postoperative periods.

Friedli suggested classification of types of CHD correction based on the likelihood that the patient will require further follow-up surgery:

n True full correction leads to the restoration of normal cardiac anatomy and function and is usually possible with secondary defects atrial septum, ventricular septal defects, patent ductus arteriosus, coarctation of the aorta. Although late complications occasionally occur in some patients, most children experience normal life without reoperation.

n Anatomical correction with residual effects may be performed in patients with tetralogy of Fallot, atrioventricular septal defects, and valvular obstructions repaired by valvotomy or valve repair. In these patients, symptoms and abnormal physiology disappear, but residual defects such as valvular insufficiency or arrhythmias remain, which may require further intervention.

n Correction using prosthetic materials used in patients who require an anastomosis between the right ventricle and the pulmonary artery (for pulmonary atresia with VSD). Due to somatic growth and degeneration of the prosthetic material, this category of patients will require reoperation to replace a prosthesis.

n Physiological correction(operations Senning And Mustard about the transposition of the main arteries, Fontan operation in patients with a three-chamber heart) eliminates disorders cardiovascular physiology, but does not eliminate anatomical disorders. These patients almost always develop late complications requiring surgical or conservative intervention.

This classification is very useful to use in the practice of a pediatrician and a pediatric cardiologist in order to predict the likelihood of problems in the operated patient and plan further follow-up.
The number of patients who underwent surgical correction of CHD is growing at a rate much higher than the growth in the number and workload of pediatric cardiologists. As a result of this, the district pediatrician will be forced to assume responsibility for monitoring this complex group patients. The pediatrician must be aware of any remaining disorders and potential complications that may develop in order to refer the patient to a specialist in time.

We hope that the issues of classification, diagnosis and dispensary observation of children with congenital heart disease presented in this manual will help to establish the diagnosis in a timely and correct manner and reduce the incidence of complications in patients with this pathology.

Careful outpatient dispensary control helps prevent the occurrence or progression of complications in children with congenital heart disease in the pre and postoperative periods.

LIST OF USED LITERATURE

1. Belokon of the heart and blood vessels in children // Moscow Volume 1.- p. 447.

2., Podzolkov heart defects // Moscow– p. 350.

3. Mutafyan heart defects in children // Moscow. - 2002. - p. 330.

5., Sinkovskaya diagnosis of congenital heart defects // Children's diseases of the heart and blood vessels No. 1. - S. 39-47.

7., Galdina clinics and diagnosis of heart failure in childhood and the principles of its treatment // Bulletin of Arrhythmology. - 2000. - No. 18.-S. 38-40.

8. Tabolin on pharmacotherapy in pediatrics and pediatric surgery. Clinical cardiology // M.-2004.-p.161.

9. Shkolnikova cardiology in Russia at the turn of the century // Bulletin of arrhythmology. - 2000. - No. 18. - S. 15-22.

10. Wielenga R. P., Huisveld I. A., Bol E. Safety and effects of physical trainning in chronic heart failuar // Eur. Heart J. - 1999. - No. 20. – P. 872-8

List of abbreviations

AVK, atrioventricular communication;

BP - blood pressure;

ADLV, abnormal pulmonary venous drainage;

congenital heart disease

GLS - main pulmonary trunk;

DDA - double arc aorta;

VSD - ventricular septal defect;

ASD - atrial septal defect;

EZhS - the only ventricle of the heart;

IE, infective endocarditis;

CA, coarctation of the aorta;

OAP - open ductus arteriosus;

OSA, common truncus arteriosus;

MVP - mitral valve prolapse4

SA, aortic stenosis;

PLA, pulmonary artery stenosis;

HF, heart failure;

TMS - transposition of the great vessels;

TF, tetrad of Fallot;

Annex 1.

Division of congenital heart defects depending on

from the age chronology of the first symptoms

Defects that manifest only in newborns	Defects that manifest mainly in newborns	Malformations in newborns, most often not accompanied by hemodynamic disorders	Vices that manifest in all age groups
1. Hypoplasia of the left half of the heart 2. Pulmonary valve atresia 3. Complete anomalous pulmonary venous drainage 4. Prenatal narrowing or fusion of the oval window	1. Complete transposition of the aorta and pulmonary artery 2. Common true truncus arteriosus 3. Two-chambered heart	1. Atrial septal defect 2. Ventricular septal defect 3. Tetralogy of Fallot (except for cases with a 4. 9atresia of the pulmonary artery)	2. Coarctation of the aorta 3. Aortic stenosis 4. Stenosis of the valves of the pulmonary artery 5. Tetralogy of Fallot with pulmonary atresia 6. Atresia of the tricuspid valve 8. Ebstein's disease abnormal pulmonary venous drainage 10. Atrioventricular valve

Appendix 2

Principles of organization of care for newborns with congenital heart disease:

1) timely detection of children with suspected CHD in the maternity hospital;

2) topical diagnosis of the defect;

4) timely surgical treatment.

All children with suspected congenital heart disease should be examined by a cardiologist, referred to a specialized hospital and then to cardiology centers to establish a topical diagnosis of the defect. During examination in a hospital (general clinical examination, ECG, FCG, radiography in three projections, echocardiography with dopplerography, measurement of blood pressure in the upper and lower extremities, exercise tests and pharmacological tests), a detailed diagnosis should be made indicating the topic of CHD, the degree of pulmonary hypertension , phases of the course of the defect, functional class, degree of heart failure, the nature of complications and concomitant diseases. In all cases of congenital heart disease, a consultation with a cardiac surgeon is necessary to resolve the issue of indications and timing of surgical correction of the defect.

If there are signs of circulatory disorders, drug cardiotonic, cardiotrophic and restorative therapy is carried out. Patients with HF 1-2st need only cardiotrophic and restorative therapy (treatment of dystrophy, anemia, hypovitaminosis, immunocorrection). Patients with HF grade 3-4 after active cardiotonic and diuretic therapy (except for patients with TF, hypertrophic subaortic stenosis) and treatment with vasodilators (ACE inhibitors) are discharged under outpatient supervision by a cardiologist and pediatrician. They are recommended prolonged treatment with maintenance doses of cardiac glycosides, ACE inhibitors, potassium and magnesium preparations, cardiotrophics.

Patients with CHD are discharged from the hospital (with the timing of the next planned hospitalization) under outpatient supervision by a cardiologist and pediatrician.

Children of the first month life with CHD are observed by a cardiologist weekly, in the first half of the year - 2 times a month, in the second - monthly, after the first year of life - 2 times a year. At least once a year, and sometimes more often, the patient should be routinely examined in a hospital, including being examined by a cardiac surgeon, for dynamic control, dose adjustment of maintenance therapy, sanitation of foci of infection. At the same time, it is necessary to record an ECG at least once a quarter, conduct an echocardiogram 2 times a year and a chest x-ray once a year.

The existing opinion about a significant limitation of the motor activity of patients with CHD in recent years is considered incorrect. Physical inactivity only worsens the functional state of the myocardium, especially against the background of the natural, age-related physical activity of the child's body. Taking into account the characteristics of each CHD, it is necessary to conduct regular exercise therapy classes according to a lightweight program, courses of therapeutic massage, tempering procedures.

Preventive vaccinations are contraindicated in complex cyanotic malformations or pale-type CHD with heart failure of 3-4 functional classes, as well as in the presence of signs of current subacute bacterial endocarditis.

Psychological rehabilitation.

Patients with cyanotic heart disease, occurring with thickening of the blood, impaired rheology, polycythemia, to prevent possible thrombosis, especially in the hot seasons of the year, should consume a sufficient amount of fluid, and also take anticoagulants and antiplatelet agents (curantyl, phenylin) in small doses.

Sanitation of chronic foci of infection (consultation of a dentist and an otolaryngologist 2 times a year).

To prevent the development of infective endocarditis, it is necessary to identify risk groups for IE, which include:

All patients with CHD, especially cyanotic ones, all patients operated on for CHD, especially with patches made of synthetic material; - patients with CHD who have valve prostheses installed as a result of surgery; - patients cured of infective endocarditis.

Particularly threatened by the occurrence of IE are patients with operated CHD in the first 2-6 months. after surgery, with weakened immunity, festering wounds, a tendency to pyoderma and furunculosis, as well as chronic foci of infection.

Primary prevention of IE in all children with congenital heart disease - clinical examination by a cardiologist with a planned quarterly examination (general blood and urine tests, blood pressure, ECG), echocardiography - 2 times a year, chest x-ray 1 time per year. Consultation of a dentist and an otolaryngologist - 2 times a year, with the layering of intercurrent diseases (ARVI, tonsillitis, bronchitis, etc.), it is necessary to carry out antibiotic therapy (penicillins, macrolides orally or intramuscularly for 10 days).

Minor surgical operations (tonsillectomy, adenectomy, extraction of teeth, filling teeth of the lower gum level, surgical treatment of boils and other surgical procedures, as well as the installation of venous catheters, hemodialysis, plasmapheresis) and other interventions that can cause short-term bacteremia should be carried out strictly according to indications and under the cover of antibiotics). Antibiotics (semi-synthetic penicillins or macrolides) are prescribed 1-2 days before surgery and within 3 days after it.

After heart surgery, especially in the first 2 - 6 months, it is necessary to conduct daily thermometry. A general blood and urine test is performed during the first month after the operation every 10 days, during the first half of the year - 2 times a month, and during the second half of the year - monthly. Registration of ECG, EchoCG in the first half of the year is carried out quarterly, and then 2 times a year, chest x-ray 1 time per year. After discharge from the surgical cardiac center, the child is sent for examination to the hospital of the cardiology department after 3 months to consolidate the effect, conduct an examination, a course of immunomodulatory, cardiotrophic and vitamin therapy, and exercise therapy.

Spa treatment it is recommended to carry out in the conditions of local cardio-rheumatological sanatoriums. It is shown annually to patients with CHD for 60-120 days a year, before and after surgery. Contraindications to the stay of children in a sanatorium: severe circulatory disorders, heart failure of 3-4 functional classes, signs of current subacute bacterial endocarditis, a period of less than three weeks after an intercurrent disease and a year after surgery.

Children are not removed from the dispensary registration and are transferred under the supervision of a therapist. Careful outpatient dispensary control helps prevent the occurrence or progression of complications in children with congenital heart disease in the pre and postoperative periods.

In the first phase of vice the frequency of examination by a pediatrician of children with CHD without hemodynamic disturbances 2 times a year; after inpatient treatment for 6 months monthly, then 1 time in 2 months up to a year .. Cardio-rheumatologist examines the child 2-4 times a year severe course(defect of the "blue type", pulmonary hypertension, etc.) 1 time in 1-2 months. Consultation of a dentist and an ENT doctor 2 times a year, other specialists - according to indications. A cardiac surgeon consults a child when establishing a diagnosis, then according to indications. Children who have undergone CHD operations, including palliative ones, are examined once every 2-3 months in the first year after the intervention, then 1-2 times a year.

Examination methods: blood tests, urine tests 2 times a year, X-ray examination 1 time per year, Echo-KG, ECG 1 time in 6 months. Other studies according to indications.

Indications for hospitalization: clarification of the diagnosis of congenital heart disease, the appearance of symptoms of decompensation, severe hypoxemic crises, the development of complications, intercurrent diseases. Surgical sanitation of foci of chronic infection not earlier than 6 months after surgery for heart disease. Contraindications for surgical debridement of foci of infection are the presence of symptoms of decompensation, hemorrhagic diathesis in children with the third phase of blue defect, and complications from the central nervous system.

One of the main tasks of CHD rehabilitation is the compensation of heart failure. The mode of a child with congenital heart disease provides for widespread use fresh air both at home and outdoors. The temperature should be maintained within 18-20 degrees with frequent ventilation. The participation of a child in outdoor games with other children should be determined not by the nature of the defect, but by its compensation and the child's well-being. Children with CHD limit their own motor activity. In the presence of CHD with unimpaired hemodynamics, children are engaged in kindergarten in a weakened group, and at school in preparatory groups. In the presence of hemodynamic disorders, a special group is assigned permanently, exercise therapy. After heart surgery exemption from physical education for 2 years, permanently exempted with symptoms of cardiac or lung failure. Twice a year (in spring and autumn) a course of treatment with cardiotropic drugs is carried out: riboxin, cocarboxylase, ATP, corhormone, intercordin, potassium orotate, glutamic acid, vitamin therapy.

Physical education classes in the absence of hemodynamic disorders - in the preparatory group, in the presence of hemodynamic disorders - in ad hoc group constantly or exercise therapy. After heart surgery, exemption from physical education for 2 years.

Dispensary observation before transfer to an adult clinic, after surgical treatment, the issue of clinical examination is resolved individually. Health group III-V.

MITRAL FAULTS

Clinical examination

Patients with valvular heart disease are observed by a family doctor or a local therapist during consultations of a rheumatologist and a cardiologist according to the nosological principle in the groups "rheumatic fever", "rheumatoid arthritis", "Ankylosing spondylitis", "systemic lupus erythematosus", etc.

The frequency of inspections is at least 4 times a year. The scope of the examination - clinical analysis of blood, urine, X-ray examination of the chest, ECG, FCG, echocardiography, biochemical blood tests - acute phase reactions, glycosaminoglycans. If necessary, consultations of an ENT specialist, dentist, ophthalmologist, neuropathologist. According to indications - consultation of the cardiosurgeon.

Complex medical measures determined by underlying disease clinical symptom complexes- heart failure, arrhythmias, etc.

Criteria for the effectiveness of clinical examination: reduction in the frequency of recurrence of the disease, reduction in the period of temporary disability, the number of patients who have become disabled.

Mitral stenosis is a common acquired heart disease. It can be observed in a "pure" form or in combination with mitral valve insufficiency.

Etiology. Almost all cases of mitral stenosis are the result of rheumatism. Quite often in the anamnesis of such patients (up to 30-60% of cases) there are no obvious rheumatic attacks, however, there should be no doubt about the rheumatic origin of the defect.

Mitral stenosis usually develops at a young age and is more common in women.

Pathogenesis. Hemodynamic changes . In humans, the area of ​​the left atrioventricular opening ranges from 4-6 cm 2 . It has a significant reserve of area, so only its reduction by more than half can cause noticeable hemodynamic changes.

The narrowed mitral opening serves as an obstacle to the expulsion of blood from the left atrium, therefore, to ensure normal blood supply to the left ventricle, a number of compensated mechanisms are activated.

In the atrial cavity, the pressure rises (from 5 mm Hg to 25 mm Hg). This increase in pressure leads to an increase in the pressure difference between the left atrium and the left ventricle, thereby facilitating the passage of blood through the narrowed mitral orifice. Left atrial systole lengthens and blood enters the left ventricle for a longer time. These two mechanisms - the increase in pressure in the left atrium and the lengthening of the systole of the left atrium at first compensate bad influence narrowed mitral orifice on intracardiac hemodynamics.

The progressive decrease in the opening area causes a further increase in pressure in the cavity of the left atrium, which simultaneously leads to a retrograde increase in pressure in the pulmonary veins and capillaries. In some patients (30%), a further increase in pressure in the left atrium and pulmonary veins due to irritation of baroreceptors causes a reflex constriction of arterioles (Kitaev's reflex). This defensive reflex protects the pulmonary capillaries from an excessive increase in pressure and sweating of the liquid part of the blood into the cavity of the alveoli. Subsequently, a prolonged spasm of arterioles leads to the development morphological changes. This creates a second barrier to blood flow, thereby increasing the load on the right ventricle. As a result, its hyperfunction and hypertrophy reach pronounced degrees. A significant increase in pressure in the pulmonary artery and right ventricle makes it difficult to empty the right atrium, which is also facilitated by a decrease in the ventricular cavity due to its pronounced hypertrophy. Difficulty in expelling blood from the right atrium causes an increase in pressure in its cavity and the development of hypertrophy of its myocardium.

Incomplete emptying of the right ventricle during systole leads to
an increase in diastolic pressure in its cavity. Developing dilatation of the right ventricle and relative insufficiency of the tricuspid valve somewhat reduce the pressure in the pulmonary artery, but the load on the right atrium increases to an even greater extent. As a result, decompensation develops in a large circle.

Clinic. From the analysis of the pathophysiological features of the defect, it follows that the clinical picture of the disease at different stages of its development will differ in some features. However, in all patients with mitral stenosis, objective signs should be observed, depending solely on the characteristics of the valve lesion.

Complaints. If mitral stenosis is not pronounced and is compensated by increased work of the left atrium, then patients may not complain. They are able to perform a fairly significant physical activity. With an increase in pressure in a small circle, there are complaints of shortness of breath during physical exertion. Another complaint is a cough, dry or with a small amount of mucous sputum, often with an admixture of blood. With high pulmonary hypertension, patients often complain of fatigue, weakness, because there is no adequate increase in cardiac output.

With the appearance of congestion in a small circle, patients during exercise often complain of palpitations. Sometimes angina pectoris. Their cause may be: 1) stretching of the left atrium; 2) stretching of the pulmonary artery; 3) compression of the left coronary artery enlarged left atrium.

objective data.

Inspection. The appearance of a patient with moderately severe stenosis does not present any features. With an increase in the symptom of pulmonary hypertension, a typical facies mitralis is observed: against the background of pale skin, a sharply defined “mitral” blush of the cheeks with a somewhat cyanotic tint is observed.

Visually, the region of the heart bulges - there is a “heart hump”. This symptom is associated with hypertrophy and dilatation of the right ventricle and with its increased impacts on the anterior chest wall.

Noteworthy is the absence of an apex beat, since the left ventricle is pushed aside by the hypertrophied right ventricle.

Palpation. If, after a preliminary physical load, the patient is laid on his left side, then when holding the breath in the exhalation phase, diastolic trembling - “cat's purr” - can be determined at the apex of the heart. This symptom is caused by low-frequency fluctuations of the blood as it passes through the narrowed mitral orifice. In the 2nd intercostal space to the left of the sternum, palpation with the palm of the hand in the exhalation phase can determine the amplification (accent) of the II tone. Nesterov B.C. (1971) describes the symptom of "two hammers": if the hand is placed on the region of the heart so that the palm is projected onto the top, and the fingers are projected onto the region of the second intercostal space to the left of the sternum, then clapping 1 tone is felt by the palm as the first "hammer", and the accented II tone is perceived by the fingers as a blow of the second "hammer".

In the upper part of the epigastrium, a pulsation can be observed, depending on hard work hypertrophied right ventricle: on inspiration, this pulsation increases sharply, as blood flow to the right ventricle increases.

Percussion. With percussion relative stupidity the heart is enlarged upward due to the left atrial appendage and to the right due to the right atrium.

Auscultation. It gives the most significant signs for the diagnosis, since the detected phenomena are directly related to impaired blood flow through the mitral opening.

Tone I is reinforced (clapping). This depends on the fact that in the preceding diastole, the left ventricle is not filled sufficiently with blood and contracts rather quickly. At the apex, the mitral valve opening tone (opening click) is also heard immediately after the second tone. Clapping tone I in combination with tone II and the opening tone will create a characteristic melody at the top of the heart - “quail rhythm”.

The characteristic auscultatory symptoms in mitral stenosis include diastolic murmur. The noise is associated with the movement of blood through the narrowed mitral orifice due to the pressure gradient left atrium - left ventricle.

The pulse is usually not an indicator characteristic changes. The pulse is slightly less than normal filling as a result of a decrease in cardiac output.

R-logical research. The purpose of this study is to more accurately determine the enlarged sections of the chambers of the heart, as well as to find out the state of the vessels of the small circle.

ECG turns out to be very valuable in the diagnosis of mitral stenosis and the assessment of the stage of its course. The purpose of the ECG is to identify hypertrophy of the left atrium and right ventricle, the presence of rhythm disturbances.

Signs of left atrial hypertrophy: 1) double-apex P wave in lead I, AVL, V4-6; 2) in lead V1, there is a sharp increase in amplitude and duration of the second phase of the P wave; 3) an increase in the time of internal deviation of the P wave by more than 0.06 sec.

Signs of right ventricular hypertrophy: 1) deviation of the electrical axis of the heart to the right in combination with a shift in the ST interval and a change in the T wave in AVF, III; 2) the R wave increases in the right chest leads, and the S wave increases in the left chest leads.

FKG- graphic recording of heart sounds and heart murmurs. The value of FKG increases in conditions when, during auscultation, it is difficult to attribute the audible noise to one or another phase of the cardiac cycle.

ECHO-KG is currently essential for the diagnosis of mitral stenosis.

Diagnostics.

Direct signs: 1) clapping I tone; 2) mitral valve opening tone (opening click); 3) diastolic noise; 4) diastolic trembling (palpation); 5) ECHO-KG - signs of mitral stenosis.

Indirect signs: 1) R-logical and ECHO-KG signs of left atrial enlargement; 2) ECG - left atrial hypertrophy; 3) shortness of breath on exertion; 4) attacks of cardiac asthma; 5) pulsation in the epigastrium due to the right ventricle; 6) R-logical and ECHO-CG signs of right ventricular hypertrophy.

Treatment. There is no specific conservative treatment for mitral stenosis. Circulatory failure is treated according to generally accepted methods (cardiac glycosides, diuretics, potassium preparations). With an active rheumatic process - antirheumatic drugs, antibiotics. Surgical method treatment - commissurotomy.

Surgical treatment is only an integral part in a complex complex rehabilitation measures patients with rheumatic heart disease. 3-4 weeks after the operation, patients return to pediatricians and therapists for further rehabilitation and consolidation of the effect achieved by the operation.

Strict accounting and systematic monitoring of patients in clinics and dispensaries is carried out in order to timely prevent and detect exacerbations of rheumatism, circulatory compensation disorders, and the state of the coagulation system.

In the first 2-3 months after the operation, children should be examined weekly, then up to a year - at least once a month. For uncomplicated course postoperative period control examinations of patients in surgical clinics are carried out 6 months after the operation, then annually, and if necessary, more often.

All operated patients are recommended a three-year continuous course of treatment with bicillin-5, and in subsequent years - seasonal spring and autumn courses of antirheumatic therapy. It is advisable for children to carry out continuous antirheumatic treatment until growth is completed. Sanitation of foci of infection with tonsillitis, otitis media, dental caries is essential. gastrointestinal diseases. If it is necessary to perform operations for these diseases, protective 10-14-day courses of antibiotic treatment are advisable.

If the operation was performed with incomplete correction of defects or there are pronounced secondary changes in the lungs, myocardium and other organs, treatment with cardiac glycosides, diuretic drugs, enzymes and vitamins under the control of blood electrolytes and ECG is indicated on an individual basis.

It is allowed to attend school 2-3 months after the operation. In adolescents and in the long term after surgery, already in adulthood patients have to deal with employment issues. In most cases, with uncomplicated mitral stenosis and adequate commissurotomy in the first 6 months, it is advisable to assign group II disability, and subsequently - group III with limitation physical activity. A year after the operation, it is possible to restore working capacity without any restrictions.

In case of residual defects and complicated operations with symptoms of circulatory compensation disorders, the issue of disability after 6 months after the operation is decided on an individual basis. It is advisable to keep the II or III disability group for the period necessary for the full stabilization of compensation.

Patients with prosthetic heart valves usually undergo surgical treatment in more severe (IV) stages of the disease and, in addition to persistent antirheumatic therapy, as a rule, require treatment with cardiac glycosides, diuretics and anticoagulants.

After discharge from the hospital, they should be sent to specialized sanatoriums.

In order to prevent thromboembolism after prosthetics of the left atrioventricular valve, it is necessary to constantly use anticoagulants indirect action maintaining the prothrombin index at the level of 50-70%. The dose is selected individually, the treatment is carried out in a hospital and on an outpatient basis under the control of blood coagulation.

Monitoring of the prothrombin index is carried out monthly, and with its fluctuations and changes in the dose of the anticoagulant - more often.

In case of increased bleeding (hemorrhage, hematuria, menorrhagia), as well as the need for a planned operation (tonsillectomy, tooth extraction, etc.), it is necessary to reduce the dose of anticoagulant and increase the prothrombin index to 70-75%. It is not advisable to completely cancel the drug.

When examining the working capacity of patients with valve prostheses, it must be remembered that operations are performed in severe patients with severe secondary changes in the heart and other organs. Therefore, the operation cannot fully restore the child's ability to work, as after the elimination of stenosis using a closed technique. Due to the difficulty of solving this problem in Lately more and more attention is paid to objective methods and quantitative assessment of working capacity.

The principles and recommendations for the rehabilitation of these patients, developed by J. A. Bendet and co-authors, have the following quantitative expression: the workload of a working day for patients with valve prostheses should not exceed one third of the maximum tolerable energy expenditure, determined using a stress test. Moreover, the initial load power during the test should not exceed 0.98 kJ / min (100 kgm / min). With good tolerance, it increases to 170 in 1 min. The assessment of labor opportunities can be carried out according to the criteria proposed by N. M. Amosov and Ya. A. Bendet, who distinguish 5 groups according to the threshold load.

The first (workable) - with a load tolerance of more than 7.35 kJ / min (750 kgm / min) for women and 8.82 kJ / min (900 kgm / min) for men.

The second (moderately limited) - with a load tolerance of 4.90-7.35 kJ / min (501-750 kgm / min) for women and 5.88-8.82 kJ / min (601-900 kgm / min) for men.

The third (significantly limited) - with a load carrying capacity of 2.94-4.90 kJ / min (301-500 kgm / min) for women and 2.94-5.88 kJ / min (301-600 kgm / min) for men.

The fourth (inoperable) - with load tolerance in the range of 0.98-2.94 kJ / min (100-300 kgm / min) for women and men.

And, finally, the fifth (requiring care) group includes patients with a load tolerance of less than 0.98 kJ/min.

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Rheumatism is the most familiar name for this inflammatory disease for us, although in the literature it is sometimes called Sokolsky-Buyo disease or rheumatic fever, which does not change its essence at all.

About 30-40 years ago, the spread of rheumatism was quite wide. Mostly, among the sick were often and long-term ill children from 6 to 14-15 years old, with foci of chronic infection (tonsillitis), low immunity and hereditary predisposition to heart disease. The appearance of the first attack in adulthood is no exception, but the onset of the disease in adults is a rather rare phenomenon.

Modern medicine knows many ways to deal with this very serious illness, the path of which is directed straight to the defeat of the heart and the formation of valvular defects. Diagnostic search using new techniques and high-precision equipment, effective drugs and effective preventive measures make it possible to stop the pathological process at the beginning of its inception.

Causes of rheumatic fever

The greatest importance in the formation of the inflammatory process of the connective tissue with subsequent damage to various membranes of the heart belongs to β-hemolytic streptococcus (group A), which often settles in the upper respiratory tract to provoke an acute respiratory viral disease with reduced immunity. That is why quite often rheumatism debuts after a sore throat or other related pathological conditions.

Despite the high incidence of acute respiratory viral infections and tonsillitis in children, not everyone reaches rheumatism, therefore it is believed that one hemolytic streptococcus is not enough for the development of the disease. We need conditions and prerequisites that will assist the infectious agent to win over the organism.

Low or, conversely, excessively high (hyperimmunoreactivity) immune response, genetically programmed predisposition, poor living conditions and adverse factors external environment leave a person unprotected and open pathogenic microorganisms the road to the connective tissue of the heart, which has an antigenic composition similar to streptococcus. Immune reactions begin to take place in the membranes of the heart, accompanied by the formation of anticardiac immunoglobulins (autoantibodies), aimed at the tissue of one's own heart, and not at fighting the enemy. As a result, the titer of unnecessary antibodies grows, and the heart is affected.

In addition, the occurrence of a rheumatic process is often associated with the presence of certain leukocyte alloantigens inherited from parents and the formation of cross-reactive immunoglobulins directed to streptococcus, but capable of interacting with antigens of the HLA system (tissue antigens). This phenomenon is called molecular mimicry and is considered very significant in the development of autoimmune processes, which include rheumatism.

What follows from the classification

The rheumatic process affects, as a rule, different organs and systems. Many associate the development of the disease with articular syndrome, which, however, holds the second place after damage to the connective tissue of the heart, which has the status of a leader. The course of the disease almost always goes with damage to the heart, namely, its membranes. But depending on which of them is more “liked” for a permanent habitat, rheumatic heart disease (the common name for the pathology) can be represented by:

• Endocarditis;
• myocarditis;
• pericarditis;
• Pancarditis (all membranes are affected at the same time).

In addition, the classification of rheumatism may imply a division according to other parameters:

1. An acute rheumatic process of high activity with a sudden onset, characterized by pronounced symptoms that require a quick response and intensive treatment that gives a good effect;
2. Subacute moderately active form diseases with an attack duration of up to six months, less pronounced clinical manifestations and therapeutic effect
3. Monotonous protracted process, no different high activity, lasting more than six months and manifested in most cases by some one syndrome;
4. Continuously recurring undulating course, which is characterized by bright exacerbations and incomplete remissions, numerous syndromes and progression of the pathology of many organs;
5. The latent variant of rheumatism goes unnoticed by the patient, since neither clinical, nor laboratory, nor instrumental methods diagnostics do not indicate a latent inflammatory process. The disease is detected only after a defect has formed in the heart.

It should be noted that in children the course of rheumatism is more acute and severe than in adults. Subacute and latent variants are much less common, and the acute period is accompanied by symptoms of severe intoxication and organ damage (heart, joints, brain). Sometimes, against the background of a fever, several systems are involved in the process at once.

In children in the acute phase, the disease can last up to 2 months from the onset of the attack, and in the active phase it can drag on for up to a year.

The subacute and latent course of the disease, as a rule, is an accidental finding during the examination and, unfortunately, often belated, since the acquired heart disease has already managed to form and even manifest itself clinically, which was the reason for the examination.

A continuously recurrent process for childhood is considered to be very unfavorable in terms of prognosis, since in the vast majority of cases it leads to the formation of valvular heart disease.

Clinical picture of the disease

Since inflammation first of all begins to disable the cardiovascular system, it is advisable to consider the symptoms of rheumatism primarily from this position and divide them into cardiac (primary) and non-cardiac.

It should be noted that the symptoms of the very first attack, when there is no defect yet, are distinguished by the most vivid and distinct signs. rheumatic lesion, That's why clinical picture disease can be represented as an outbreak of acute rheumatic fever (ARF):

• Acute onset (rheumatic attack) that occurs a week or two after a sore throat, SARS or any adenovirus infection;
• High body temperature, sometimes reaching up to 40 ° C;
• Migratory arthritis, sometimes serositis (inflammation of the serous membrane).

However, it is not so rare that the rheumatic process begins with low-grade fever, pain that worsens when walking (climbing stairs) and a slight swelling in knee joints(in one or both).

The initial symptoms of the disease characterize the variant of its further course very little, so you should not make an attempt to predict the prognosis. The most reasonable thing in this situation would be to see a doctor, because for the development of a rheumatic process, even one hour can play a role and prevent terrible complications in the form of a defect, myocardiosclerosis or heart failure. It should not be forgotten that the latent course very often contributes to the quiet and imperceptible formation of valvular defects, so treatment should be started as early as possible.

Given that rheumatism is a systemic diseases, the main feature of which is the active involvement of various organs in the process, it is multi-syndromic, so it is desirable to consider all the nuances from this point of view.

Joint and heart damage

The missed clear picture of active rheumatism at the first stage can make it difficult to diagnose it later, when a heart disease is formed, blood circulation is disturbed, and the pathological process has passed into a chronic relapsing course. Therefore, it is very important not to miss the first attack, not to attribute it to another disease, to prevent involvement of the heart and the formation of irreversible consequences.

Since the acute onset of the disease has already been described above, we can proceed to the forms of the rheumatic process and their manifestations:

The reaction of the nervous system

Basically, by rheumatic fever people mean severe illness hearts. Obviously, this is true, however, although to a lesser extent, the process can affect other organs. For example, if primary rheumatism gets to the nervous system, then there is a chance of developing chorea minor, which is also among the leaders, as it confidently holds the 3rd place in frequency of occurrence in children, where for some reason it gives preference to girls.

The classical course of the disease can last up to 3 months, but usually this boundary does not cross, however, recently, chorea minor has also begun to “mask”, like many other diseases. Instead of the classic form of chorea minor, you can often find an erased version, the course of which is delayed and becomes undulating. But, in general, chorea minor has five significant features that determine its diagnosis:

• The appearance of erratic violent muscle movements. This phenomenon is scientifically called choreic hyperkinesis and can occur anywhere (neck, face, torso, upper and lower limbs);
• Disorder of coordination of movements that the child ceases to control and finds it difficult to do something purposefully (walk or stand in one place);
• The predominance of muscle hypotension with general dystonia of the muscles, which sometimes become flabby and change so much that they resemble paralysis;
• The phenomena of vegetative-vascular dystonia with minor chorea are not uncommon;
• Inherent in chorea emotional lability is the result of psychopathological disorders that have arisen against the background of the rheumatic process, and not a feature of adolescence or the costs of education.

Other changes in the nervous system in Sokolsky-Buyo disease (encephalitis) are considered an extremely rare case and are characteristic of childhood.

Other organs also suffer from rheumatism

Damage to other organs in the rheumatic process occurs with different frequency (usually rare) and manifests itself:

1. Ring-shaped erythema (pale pink rash on the skin of the arms, legs and torso), which is more characteristic of primary rheumatism and is even considered one of its diagnostic signs;
2. The appearance of rheumatic nodules in the form of painless formations of various sizes, round and inactive. They are localized mainly on the extensor surfaces of small and large joints(metacarpophalangeal, ulnar, knee, etc.) and tendons (heel, ankle area, etc.). However, rheumatic nodules are given important role in diagnosis, so they refer to significant criteria establishing a diagnosis;
3. A very rare occurrence for Sokolsky Buyo's disease is rheumatic pulmonary vasculitis and rheumatic pneumonitis, which are treated primarily with antirheumatic drugs, since antibiotics give a weak healing effect. But the development of rheumatic pleurisy, which gives adhesive phenomena, is observed in approximately a third of patients and is detected by radiography of the lungs;
4. Abdominal syndrome in the form of peritonitis, which in rheumatism is characteristic mainly of children and adolescence and manifests itself: a sudden increase in body temperature, cramping abdominal pain, nausea, sometimes with vomiting, constipation or frequent stools;
5. Kidney damage occurring in acute period rheumatic fever and characterized by great difficulties in the diagnostic search.

Dependence of rheumatic fever on sex and age

The younger school age with the same frequency for boys and girls is more characterized by an acute onset of the rheumatic process with bright and multi-syndromic symptoms, where polyarthritis and rheumatic heart disease are often accompanied by chorea, erythema and nodules.

In adolescents, the disease proceeds somewhat differently: it “loves” girls more, it begins with slowly developing rheumatic heart disease, against which heart disease often develops, and the disease itself acquires a protracted relapsing character.

A special group of patients with rheumatism are young men who have left childhood and adolescence, entered adolescence and, in most cases, are able to pay military duty to the Motherland. Of course, when a young man arrives during this period already with a certain baggage of rheumatic diseases, his presence in the ranks of the recruits is called into question. Another question is if the disease caught the young man at this age. The excitement of the parents and the guy himself is quite understandable, so they are eager to learn more about the disease itself and its prospects.

In adolescence, the disease is characterized mainly by an acute onset (ARF) with clearly defined syndromes:

• Rheumocarditis;
• polyarthritis;
• Annular erythema.

Most likely, the disease at this age, with timely treatment started, will end in complete recovery and will not remind of itself in the future. But there are exceptions to every rule: heart disease is formed in 10-15% of young people.

As for adults, they practically do not get sick with acute rheumatic fever. But cases of recurrent rheumatic heart disease (mainly in women) are not so a rare event. Cardiac pathology acquires a protracted progressive character and after 10-15 years is manifested by combined and combined heart defects. Simple measures can save the situation and improve the prognosis of later life: dispensary observation, adequate treatment and preventive measures.

Video: story about childhood rheumatism

How to recognize the rheumatic process?

The very first steps in the diagnostic search are:

• Collection of rheumatic anamnesis, where special emphasis is placed on infections transferred in the recent past;
• Examination of the patient to identify symptoms of rheumatism: polyarthritis, rheumatic heart disease, chorea, etc.);
• Auscultation (appearance or intensification of noise in the apex of the heart or aorta, rhythm disturbance);

An important role in the diagnosis of rheumatism is assigned to the appointment of a blood test to determine:

1. Erythrocyte sedimentation rate - ESR and values leukocyte formula(usually a detailed analysis is immediately prescribed);
2. C-reactive protein (normally negative);
3. The titer of antibodies directed to streptococcus (antistreptolysin - ASL-O) and intensively "multiplying" in rheumatism;
4. Rheumatoid factor (RF), which is normally negative.

Priority activities also include:

• Sampling of material from the pharynx for the purpose of its sowing and detection of β-hemolytic streptococcus (its presence says a lot);
• An electrocardiogram (an extended P-Q interval indicates a heart disease of rheumatic origin);
• X-ray methods usually provide little information at the first attack of rheumatism, however, they are used to diagnose changes inherent in the severe course of rheumatic heart disease in children and young people;
• Ultrasound examination (ultrasound), as a rule, stating the presence or absence of a defect.

Treatment of Sokolsky-Buyo disease

The fight against rheumatic fever involves combined treatment and long-term observation, therefore, in healing process there are 3 stages:

1. The active phase, requiring a stay in stationary conditions;
2. Outpatient treatment at the place of residence with a cardiologist;
3. The period of long-term dispensary observation and prevention of recurrence of the disease.

With rheumatism, the patient is usually prescribed antimicrobial (antibiotics) and anti-inflammatory drugs (non-steroidal anti-inflammatory and corticosteroids), however, their dosages and regimens are calculated depending on the form, phase, and variant of the course of the disease. NSAIDs (non-steroidal anti-inflammatory drugs) are considered a good and effective medicine for rheumatism, therefore, in recent years, preference has been given to this group more often. In addition to anti-inflammatory, NSAIDs have a good analgesic effect, which is important when articular form rheumatism.

With an unfavorable course, there is a need for long-term complex therapy or in timely surgical intervention(heart disease), therefore, in the case of rheumatic fever, it is better to rely on the opinion of a doctor, visit him more often and follow all recommendations.

The task of the second stage in adults consists of treatment in a polyclinic and referral from this stage to a cardiological sanatorium. It is better to direct children and adolescents to a rheumatological sanatorium immediately, bypassing outpatient treatment.

The third stage usually stretches over years and consists of scheduled visits to a cardiologist, examinations, and preventive measures aimed at preventing relapse.

However, it is important to note that long-term prevention is secondary prevention. But the primary need to start immediately and immediately. It consists in the elimination of foci of chronic infections and a very vigorous treatment of acute pathological processes caused by streptococcus.

Prevention of rheumatism at home

Tablets and other forms medications, actively used in the hospital, do not want to use at home, so patients learn folk remedies treatment of rheumatism and do it at home. Of course, this is possible if rheumatism has not done a lot of things, it proceeds slowly without any particular exacerbations, although patients, as a rule, still take anti-inflammatory tablets with an analgesic effect in a pharmacy in reserve anyway.

What does informal (traditional) medicine offer us?

As an anesthetic, for example, people recommend a warm (not hot!) bath with chamomile (infusion). Although, probably, even without chamomile, a warm bath will have a beneficial effect on “rheumatism”? Especially if you take it in the evening before bed.

For anesthesia, you can use a mixture of alcohols: camphor (50 gr.) And ethyl (100 gr.), Where you should add the beaten protein of two eggs, mix well and rub into the sore joints. And you can use for such purposes gruel of grated potatoes, which can be put on a sore spot on a linen cloth.

Used as a condiment, celery is said to help with rheumatism. For this, the plant is boiled and drunk in small doses.

Rosehip is generally considered a medicinal plant, so it is also used for rheumatism. To do this, take 1.5 cups of its leaves and roots crushed in a coffee grinder, pour it with a bottle of vodka, insist for a week, but do not forget, since the future medicine needs to be shaken periodically. When it is ready, strain and drink 1 tbsp. spoon three times a day a quarter of an hour before meals. If everything goes well, then the dose can be increased to 2 tablespoons, but at the same time remember that this is still a vodka solution, it is not surprising to get used to it.

In general, on the Internet you can find different recipes treatment of rheumatism, sometimes, to put it mildly, exotic. For example, in the initial stage of the rheumatic process (most likely, we are talking about the articular form), they suggest attaching bees to the sore spot. Bee venom, of course, has anti-inflammatory properties, but often gives an allergic reaction, which must be taken into account.

They treat Sokolsky-Buyo disease with earthworms, ant baths or goat droppings, wine, fasting and much more, but such treatment, as a rule, has a local effect, but does NOT affect the cause of the rheumatic process - streptococcal infection. And she, remaining in the body, very often affects the valvular apparatus of the heart. Therefore, all preventive measures, first of all, should be aimed at increasing natural immunity(compliance with the regime of work and rest, balanced diet, saturation of the body with vitamin C, etc.), the fight against streptococcus, adequate treatment of tonsillitis, sanitation of foci of chronic infection. However, of all the listed items, the diet of patients and their relatives probably comes first.

Nutrition in rheumatic fever is practically no different from that in other cardiovascular pathologies. The patient is still in the hospital set table number 10, which is undesirable to change in the future. This diet provides for the restriction of fatty, salty, fried and smoked foods, preference is given to steamed dishes and containing sufficient (but not excessive!) The amount of proteins, carbohydrates (better in fruits than in cakes), fats (completely without them, after all, too impossible), vitamins and microelements.

The presence of a history of rheumatic fever in parents is a reason for examining children and strengthening control over their health.

Video: rheumatism in the program "Live Healthy!"

What is heart disease (congenital and acquired)

Diagnostics

Diagnosis of heart defects begins with an examination of a pregnant woman. Listening to heartbeats allows you to suspect heart disease in the fetus. The woman is examined by specialists for the viability of the unborn child. Immediately after birth, neonatologists examine the baby, listen to the baby's heart murmurs, monitor the first hours and days of life. If necessary, they are transferred to specialized children's centers.

Clinical examination of children of preschool and school age necessarily includes examination by a pediatrician and auscultation of the heart. If unclear noises are detected, the children are sent to a cardiologist, they are given an electrocardiographic and ultrasonography heart (ultrasound) and large vessels. A more objective method for studying heart murmur is phonocardiography. There is a recording and subsequent decoding of sounds. It is possible to distinguish functional noise from organic noise.

Ultrasound and Doppler echocardiography of the heart allow you to visually assess the work of different parts of the heart, valves, determine the thickness of the muscle, the presence of backflow of blood.

X-ray examination helps to diagnose the expansion of individual parts of the heart and aorta. Sometimes this option is used to contrast the esophagus. In this case, the patient takes a sip of the contrast agent, and the radiologist observes its progress. In certain heart defects, the enlarged chambers cause the esophagus to deviate. On this basis, it is possible to ascertain the presence of anatomical defects.

More functional and structural disturbances, we will analyze the main symptoms of heart defects separately for different forms of the disease.

Acquired heart defects

This disease is the most common cause of disability and death at a young age.

By primary diseases vices are distributed:

• about 90% - rheumatism;
• 5.7% - atherosclerosis;
• about 5% - syphilitic lesions.

Other possible diseases leading to a violation of the structure of the heart - prolonged sepsis, trauma, tumors.

Heart disease in adults is associated with any of these diseases. The most frequently occurring valvular defects. Under the age of 30 - insufficiency of the mitral and tricuspid valves. syphilitic aortic insufficiency manifests itself by the age of 50-60. Atherosclerotic defects occur at the age of 60 and older.

The mechanism of functional disorders

As a result of valve insufficiency, blood ejected during systole (contraction) from one section to another or into large vessels partially returns back, meets with the next portion, overflows the entire section of the heart, causes stagnation.

When narrowing the heart hole, the same difficulties are created. Through a narrow opening, blood hardly passes into the vessels or the next chamber of the heart. There is overflow and stretching.

Acquired heart defects are formed gradually. The heart muscle adapts, thickens, and the cavity in which excess blood accumulates expands (dilates). To a certain extent, these changes are compensatory in nature. Then the adaptive mechanism "gets tired", circulatory failure begins to form.

The most common defects in this group are:

• mitral valve insufficiency;
• mitral stenosis;
• insufficiency of aortic valves;
• narrowing of the mouth of the aorta;
• insufficiency of the tricuspid (tricuspid) valve;
• narrowing of the right atrioventricular orifice;
• insufficiency of valves of a pulmonary artery.

Characteristic functional disorders and symptoms of acquired defects

Mitral valve insufficiency refers to rheumatic heart disease. mitral valve(bicuspid) is located between the left atrium and ventricle. This is the most common valvular disease (3/4 of all). Only in 3.6% of cases is observed in a "pure" form. Usually this is a combination of valvular disease and stenosis of the left atrioventricular orifice (the passage between the left atrium and ventricle). Such combined vice also called " mitral defect hearts."

The rheumatic process leads to wrinkling of the valves, shortening of the tendons that ensure their work. As a result, there remains a gap through which the blood, when the left ventricle contracts, returns back to the atrium. During the next contraction, the ventricle receives more blood. As a result, its cavity expands, the muscles thicken. The adaptive mechanism does not cause a violation of the well-being of patients, allows you to perform the usual work. Decompensation develops due to the addition of stenosis due to the ongoing activity of the rheumatic process.

The first symptoms in children appear after suffering a sore throat. The child complains of fatigue in physical education classes, shortness of breath, palpitations. Toddlers stop taking part in games. In adults, the first signs of decompensation are shortness of breath when walking, especially when going uphill, a tendency to bronchitis.

The appearance of the patient is characteristic: lips with a bluish tint, blush on the cheeks. In babies, due to the increased cardiac impulse, a protrusion of the chest can form, it is called the “heart hump”. When examining and listening to the heart, the doctor diagnoses characteristic murmurs. The prognosis of the course of the disease is favorable if it is possible to stop the attacks of rheumatism at the stage of valve insufficiency and prevent the development of stenosis.

Mitral stenosis - narrowing of the left atrioventricular orifice. The most common rheumatic defect. About 60% of cases are observed in a "pure" form. The inability to push blood into the ventricle leads to the expansion of the left atrium to an enormous size. As a compensatory mechanism, the right ventricle expands and thickens. It is he who supplies blood through the lungs to the left atrium. Failure of the device leads to stagnation of blood in the lungs.

Shortness of breath - main symptom this vice. Children grow up pale, physically underdeveloped. Over time, there is a cough with frothy sputum containing blood, palpitations, pain in the heart. This symptom is especially characteristic after exercise, overwork. Small congestive veins surrounding the lung tissue are torn.

The patient is pale, cheeks, tip of the nose, lips and fingers are cyanotic. In the epigastrium, a pulsation of the heart is visible. Changed breathing is heard in the lungs. Diagnosis is not difficult. A complication is dangerous - blood clots form in the stretched left and right atria. They are able to pass through the bloodstream and cause heart attacks of the kidneys, spleen, brain, and lung. The same reason contributes to the development of atrial fibrillation. With the rapid course of rheumatism, disability of patients occurs due to severe complications.

Aortic valve insufficiency occurs with a long course of rheumatism, syphilis, chronic sepsis, is the result of severe atherosclerosis. The valves become tight, inactive. They do not completely close the outlet, through which blood flows from the left ventricle to the aorta. Part of the blood returns to the ventricle, it expands sharply, the muscles thicken. Circulatory failure first occurs according to the left ventricular type (cardiac asthma, pulmonary edema), then right ventricular manifestations join (as with mitral stenosis).

Patients are pale, a strong pulsation of the vessels of the neck is visible, a symptom of shaking the head along with pulsation is characteristic. Complaints of dizziness, headache, pain in the heart are associated with insufficient oxygen supply. A change in blood pressure is characteristic: the upper numbers are increased, the lower ones are significantly reduced. The prognosis is related to the course of the underlying disease.

Insufficiency of the tricuspid valve, located between the right sections of the heart, does not occur in a "pure" form. This defect is formed as a consequence of compensation in mitral stenosis. The manifestations of the defect are observed against the background of other symptoms. You can attach special importance to puffiness and puffiness of the face, cyanosis of the skin upper half torso.

According to the data, other acquired forms of defects account for medical statistics about 1%.

congenital heart defects

Congenital malformations are complex disorders of the development of the heart in the fetus during the embryonic stage. Exact indications of the causes of the occurrence do not yet exist. A certain role of infection of the maternal organism in the initial stage of pregnancy (influenza, rubella, viral hepatitis, syphilis), lack of protein and vitamins in the diet of the expectant mother, and the influence of background radiation have been established.

The most common defects are non-fusion:

• botallian duct;
• interventricular septum;
• interatrial septum.

Rare defects: narrowing of the pulmonary artery, isthmus of the aorta.

An isolated defect occurs in isolated cases. In most children, abnormal development results in a complex combined anatomical alteration of the heart.

An open ductus duct is necessary in the uterine period of development. It connects the pulmonary artery and the aorta. By the time of birth, this path should be closed. The defect is more common in women. It is characterized by the transfusion of blood from the right ventricle to the left ventricle and vice versa, the expansion of both ventricles. Clinical signs are most pronounced with a large hole. When small, they can go unnoticed for a long time. Treatment is only surgical, the duct is stitched and its complete closure.

A ventricular septal defect is an open hole up to 2 cm in diameter. In connection with great pressure in the left ventricle, the blood is distilled to the right. This causes expansion of the right ventricle and congestion in the lungs. The left ventricle also increases compensatory. Even in the absence of complaints in patients, characteristic murmurs are determined when listening to the heart. If you put your hand in the region of the fourth intercostal space on the left, you can feel the symptom of "systolic trembling". Treatment for decompensation of the defect is only operative: the hole is closed with synthetic material.

Atrial septal defect accounts for up to 20% of all congenital malformations. It is often part of the combined vices. Between the atria there is an oval hole, which closes in early childhood. But in some children (more often girls) it never closes. From the side of the left atrium, the hole is covered with a valve leaf and presses it tightly, since there is more pressure here. But with mitral stenosis, when the pressure in the right side of the heart increases, blood flows from right to left. If the hole is not completely closed even by a valve, then there is a mixture of blood, an overflow of the right parts of the heart. Treatment of the defect is only operational: a small defect is sutured, a large one is closed with a graft or prosthetic materials.

Complications of congenital clefts are unusual thromboembolism.

For diagnosis in these cases, an X-ray study with a contrast agent is used. Entered into one chamber of the heart, it passes through the open ducts into another.

Of particular difficulty in the treatment are combined malformations of four or more anatomical defects (tetralogy of Fallot).

Surgical treatment of congenital malformations is currently performed on early stages to prevent decompensation. Dispensary observation of patients requires constant protection against infection, control of nutrition, physical activity.

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