The structure of the aortic valve of the heart and why do AK defects occur? Aortic valve: structure, mechanism of operation. Stenosis and insufficiency of the aortic valve Aortic valve size is normal

Aortic insufficiency is a pathological change in the work of the heart, characterized by non-closure of the valve leaflets. This leads to reverse blood flow from the aorta to the left ventricle. Pathology has serious consequences.

If you do not take care of the treatment in time, then everything becomes more complicated. Organs do not receive the required amount of oxygen. This leads to an increase in heart rate to make up for the shortage. If you do not intervene, then the patient is doomed. After a certain time, the heart increases, then edema appears, due to pressure surges inside the organ, the left atrial valve may fail. It is important to contact a therapist, cardiologist or rheumatologist in time.

Aortic insufficiency is divided into 3 degrees. They differ in the divergence of the valve leaflets. It looks simple at first glance. This:

• Sinuses of Valsalva - they are located behind the aortic sinuses, immediately behind the valves, which are often called semilunar. From this place the coronary arteries begin.
• Fibrous ring - it has high strength and clearly separates the beginning of the aorta and the left atrium.
• Semilunar cusps - there are three of them, they continue the endocardial layer of the heart.

The sashes are arranged in a circular line. When the valve is closed in a healthy person, the gap between the leaflets is completely absent. The degree and severity of aortic valve insufficiency depends on the size of the gap during convergence.

First degree

The first degree is characterized by mild symptoms. The divergence of the valves is not more than 5 mm. It doesn't feel any different from normal.

Aortic valve insufficiency of the 1st degree is manifested by mild symptoms. With regurgitation, the volume of blood is not more than 15%. Compensation occurs due to increased shocks of the left ventricle.

Patients may not even notice pathological manifestations. When the disease is in the compensation stage, then therapy can be omitted, limited to preventive actions. Patients are prescribed observation by a cardiologist, as well as regular checks for ultrasound.

Second degree

Aortic valve insufficiency, which belongs to the 2nd degree, has symptoms with a more pronounced manifestation, while the divergence of the valves is 5-10 mm. If this process occurs in a child, then the signs are hardly noticeable.

If, in the event of aortic insufficiency, the volume of blood that has returned back is 15-30%, then the pathology refers to a disease of the second degree. Symptoms are not strongly expressed, however, shortness of breath and frequent heartbeat may appear.

To compensate for the defect, the muscles and the left atrial valve are involved. In most cases, patients complain of shortness of breath with light exertion, increased fatigue, strong heartbeat and pain.

During examinations using modern equipment, an increase in heartbeat is detected, the apex beat shifts slightly downward, the boundaries of heart dullness expand (to the left by 10-20 mm). When using X-ray examination, an increase in the left atrium downwards is visible.

With the help of auscultation, one can clearly hear noises along the sternum on the left side - these are signs of aortic diastolic murmur. Also at the second degree of insufficiency systolic noise is shown. As for the pulse, it is enlarged and pronounced.

Third degree

The third degree of insufficiency, also called severe, has a discrepancy of more than 10 mm. Patients require serious treatment. Most often, an operation is prescribed followed by drug therapy.

When the pathology is at the 3rd degree, the aorta loses more than 50% of the blood. To compensate for the loss, the heart organ speeds up the rhythm.

Basically, patients often complain about:

• shortness of breath at rest or with minimal exertion;
• pain in the heart area;
• increased fatigue;
• constant weakness;
• tachycardia.

In studies, a strong increase in the size of the borders of dullness of the heart down and to the left is determined. The shift also occurs in the right direction. As for the apex beat, it is reinforced (spilled).

In patients with the third degree of insufficiency, the epigastric region pulsates. This indicates that the pathology involved the right chambers of the heart in the process.

During research, a pronounced systolic, diastolic murmur and Flint's murmur appears. They can be heard in the region of the second intercostal space on the right side. They have a pronounced character.

It is important at the first, even minor symptoms, to seek medical help from therapists and cardiologists.

Symptoms, signs and causes

When aortic valve insufficiency begins to develop, the symptoms do not appear immediately. This period is characterized by the absence of serious complaints. The load is compensated by the left ventricular valve - it is able to withstand reverse current for a long time, but then it stretches and deforms a little. Already at this time there are pains, dizziness and frequent heartbeat.

The first symptoms of deficiency:

• there is a certain sensation of pulsation of the cervical veins;
• strong shocks in the region of the heart;
• increased frequency of contraction of the heart muscle (minimization of reverse blood flow);
• pressing and squeezing pain in the chest area (with strong reverse blood flow);
• the occurrence of dizziness, frequent loss of consciousness (occurs with poor oxygen supply to the brain);
• the appearance of general weakness and decreased physical activity.

During a chronic illness, the following symptoms appear:

• pain in the cardiac region even in a calm state, without exertion;
• during exercise, fatigue quickly appears;
• constant tinnitus and a feeling of strong pulsation in the veins;
• the occurrence of fainting during a sharp change in body position;
• severe headache in the anterior region;
• visible to the naked eye pulsation of the arteries.

When the pathology is in the decompensation degree, the metabolism in the lungs is disturbed (often observed by the appearance of asthma).

Aortic insufficiency is accompanied by severe dizziness, fainting, as well as pain in the chest cavity or its upper sections, frequent shortness of breath and palpitations without rhythm.

Causes of the disease:

• congenital aortic valve disease.
• complications after rheumatic fever.
• endocarditis (the presence of a bacterial infection of the inside of the heart).
• changes with age - this is due to wear of the aortic valve.
• an increase in the size of the aorta - a pathological process occurs with hypertension in the aorta.
• hardening of the arteries (as a complication of atherosclerosis).
• aortic dissection, when the inner layers of the main artery separate from the middle layers.
• violation of the functionality of the aortic valve after its replacement (prosthetics).

Less common causes are:

• aortic valve injury;
• autoimmune diseases;
• consequences of syphilis;
• ankylosing spondylitis;
• manifestations of diffuse-type diseases associated with connective tissues;
• complications after radiation therapy.

It is important to consult a doctor at the first manifestations.

Features of the disease in children

Many children do not notice problems for a long time and do not complain about the disease. In most cases, they feel good, but this does not last long. Many are still able to engage in sports training. But the first thing that torments them is shortness of breath and increased heart rate. With these symptoms, it is important to immediately consult a specialist.

At first, discomfort is noticed with moderate exertion. In the future, aortic valve insufficiency occurs even at rest. Worried about shortness of breath, strong pulsation of the arteries located on the neck. Treatment should be of high quality and timely.

Symptoms of the disease can manifest as noise in the region of the largest artery. As for physical development, in children it does not change with insufficiency, but there is a noticeable blanching of the skin of the face.

When considering an echocardiogram, aortic valve insufficiency is expressed as a moderate increase in the lumen at the mouth of the artery. There are also noises in the area of ​​the left side of the chest, which indicates the progress of the divergence between the petals of the semilunar dampers (more than 10 mm). Strong shocks are explained by the increased work of the left ventricle and atrium in the compensation mode.

Diagnostic methods

In order to correctly assess changes in the functionality of the heart and its systems, you need to undergo a qualitative diagnosis:

1. dopplerography;
2. radiography (effectively determines pathological changes in the valves and tissues of the heart);
3. echocardiography;
4. phonocardiography (determines murmurs in the heart and aorta);

During the inspection, specialists pay attention to:

• complexion (if it is pale, then this means insufficient blood supply to small peripheral vessels);
• rhythmic pupil dilation or constriction;
• language state. Pulsations, change its shape (noticeable on examination);
• shaking the head (involuntary), which occurs in the rhythm of the heart (this is caused by strong shocks in the carotid arteries);
• visible pulsation of the cervical vessels;
• cardiac impulses and their strength on palpation.

The pulse is unstable, there are recessions and increases. With the use of auscultation of the cardiac organ and its vessels, it is possible to quickly and accurately identify noises and other signs.

Treatment

At the very beginning, aortic insufficiency may not require special treatment (first degree), only preventive methods are applicable. Later, therapeutic or cardiological treatment is prescribed. Patients should follow the recommendations of specialists regarding the way of organizing life.

It is important to limit physical activity, stop smoking or drinking alcohol, and be systematically examined by ultrasound or ECG.

With medical treatment of the disease, doctors prescribe:

If the disease is in the last degree, then only surgical intervention will help.

Cases when a patient needs an urgent consultation with a surgeon:

• when the state of health has deteriorated sharply, and the reverse ejection towards the left ventricle is 25%;
• with violations of the left ventricle;
• when returning 50% of the blood volume;
• a sharp increase in the size of the ventricle (more than 5-6 cm).

Today there are two types of operations:

1. Surgical intervention associated with the introduction of the implant. It is performed when the back ejection of the aortic valve is more than 60% (it is worth noting that today biological prostheses are almost never used).
2. Operation in the form of intra-aortic balloon counterpulsation. It is done with a slight deformation of the valve leaflets (with 30% blood ejection).

Aortic insufficiency may not occur if timely preventive actions are taken against rheumatic, syphilis and atherosclerotic pathologies.

It is surgical care that helps to get rid of the problems under consideration. The timeliness and quality of taking measures can greatly increase the chance of a person returning to normal life.

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Aortic valve examination has been a strength of echocardiography since its introduction into clinical practice in the early 1970s. M-modal echocardiography was initially shown to be reliable in excluding aortic stenosis and highly sensitive in diagnosing aortic insufficiency. With the advent of two-dimensional, and then various Doppler modes, it turned out that echocardiography diagnoses aortic valve pathology so well that it surpasses cardiac catheterization and angiography in its diagnostic value.

Normal aortic valve and aortic root

Examination of the aortic valve begins with its visualization from the parasternal approach in the position of the long axis of the left ventricle. Then, under 2D image control, usually along the parasternal short axis at the level of the base of the heart, the M-modal beam is directed to the aortic valve leaflets and the aortic root (Fig. 2.2 ). On fig. 2.6 the aortic valve is shown from the position of the parasternal short axis and its M-modal image. The right coronary and non-coronary leaflets of the aortic valve fall into the slice of the M-modal image. The line of their closure in diastole is normally located in the middle between the anterior and posterior walls of the aorta. In systole, the valves open and, diverging anteriorly and posteriorly, form a "box". In this position, the valves remain until the end of systole. Normally, mild systolic trembling of the aortic valve leaflets can be recorded on M-modal examination.

If the normal thin leaflets of the aortic valve do not open fully, this usually means a sharp decrease in stroke volume. With normal stroke volume and dilatation of the aortic root, the valve leaflets, opening, may be somewhat separated from the walls of the aorta. With low stroke volume, the M-modal movement of the aortic valve leaflets sometimes has the shape of a triangle: immediately after full opening, the leaflets begin to close. If the leaflets slam shut after their maximum opening, fixed subvalvular stenosis should be suspected. Mid-systolic closure of the aortic valve cusps (partial closure in the middle of systole, then again maximum opening) is a sign of dynamic subvalvular stenosis, i.e., hypertrophic cardiomyopathy with obstruction of the outflow tract of the left ventricle. In diastole, the closed leaflets are parallel to the walls of the aorta. Diastolic trembling of the aortic valve leaflets indicates a serious pathology and is observed when the leaflets are ruptured or detached. The eccentric location of the line of closure of the aortic valve cusps makes one suspect a congenital pathology - a bicuspid aortic valve.

Movement of the aortic root can provide valuable information about the global systolic and diastolic function of the left ventricle. Normally, the aortic root is displaced anteriorly in systole by more than 7 mm, and almost immediately returns to its place at the end of it. The movements of the aortic root reflect the processes of filling and emptying the left atrium; during atrial systole, they are normally minimal. With a decrease in the amplitude of movement of the aortic root, one should think about a low stroke volume. Note that the amplitude of motion of the aortic root is not directly dependent on the ejection fraction. For example, with hypovolemia and normal contractility of the left ventricle, the amplitude of movement of the aortic root decreases. Normal or even excessive mobility of the aortic root with a reduced opening of the aortic valve cusps indicates a disproportion between the blood flow in the left atrium and in the aorta and is observed in severe mitral insufficiency.

In a two-dimensional study parasternally along the short axis, the aortic valve looks like a structure consisting of three symmetrically located, equally thin leaflets, which open completely in systole, and close in diastole and form a figure similar to an inverted emblem of a Mercedes-Benz car. The junction of all three valves may look slightly thickened. The aortic root has a larger diameter than the rest of the ascending aorta and is formed from the three sinuses of Valsalva, which are named similarly to the valve leaflets: left coronary, right coronary, non-coronary. Normally, the diameter of the aortic root does not exceed 3.5 cm. A Doppler study of blood flow through the aortic valve gives a spectrum of a triangular shape; the maximum speed of aortic blood flow is from 1.0 to 1.5 m/s. The aortic valve has a smaller diameter than the outflow tract of the left ventricle and the ascending aorta, so the velocity of blood flow is highest at the level of the valve.

Any heart disease is associated with an anomaly of the valves. Aortic valve defects are especially dangerous, since the aorta is the largest and most important artery in the body. And when the work of the apparatus that supplies oxygen to all parts of the body and the brain is disrupted, a person is practically inoperable.

The aortic valve is sometimes formed in utero already with defects. And sometimes heart defects are acquired with age. But whatever the reason for the violation of the activity of this valve, medicine has already found a treatment in such cases - aortic valve replacement.

Anatomy of the left side of the heart. Functions of the aortic valve

The four-chambered structure of the heart must work in perfect harmony to fulfill its primary function of supplying the body with nutrients and air carried by the blood. Our main organ consists of two atria and two ventricles.

The right and left parts are separated by an interventricular septum. Also in the heart there are 4 valves that regulate blood flow. They open in one direction and close tightly so that the blood moves in only one direction.

The heart muscle has three layers: endocardium, myocardium (thick muscle layer) and endocardium (outer). What is happening in the heart? The depleted blood, which has given up all the oxygen, returns to the right ventricle. Arterial blood passes through the left ventricle. We will consider in detail only the left ventricle and the work of its main valve - the aortic one.

The left ventricle is cone-shaped. It is thinner and narrower than the right one. The ventricle connects to the left atrium through the atrioventricular orifice. The leaflets of the mitral valve are attached directly to the edges of the hole. The mitral valve is bicuspid.

The aortic valve (valve aortae) consists of 3 cusps. Three flaps are named: right, left and posterior semilunar (valvulae semilunares dextra, sinistra, posterior). The leaflets are formed by a well-developed duplication of the endocardium.

The muscles of the atria from the ventricular muscles are isolated by a plate of the right and left fibrous rings. The left fibrous ring (anulus fibrosus sinister) surrounds the atrioventricular orifice, but not completely. The anterior sections of the ring are attached to the aortic root.

How does the left side of the heart work? Blood enters, the mitral valve closes, and there is a push - a contraction. Contraction of the walls of the heart pushes blood through the aortic valve into the widest artery, the aorta.

With each contraction of the ventricle, the valves are pressed against the walls of the vessel, giving a free flow of oxygenated blood. When the left ventricle relaxes for a fraction of a second to fill the cavity with blood again, the aortic valve of the heart closes. This is one cardiac cycle.

Congenital and acquired defects of the aortic valve

If there are problems with the aortic valve during the intrauterine development of the baby, it is difficult to notice. Usually, the defect is noticed after birth, since the child's blood goes around the valve, immediately into the aorta through the open ductus arteriosus. It is possible to notice deviations in the development of the heart only thanks to echocardiography, and only from 6 months.

The most common valve anomaly is the development of 2 leaflets instead of 3. This heart defect is called a bicuspid aortic valve. The anomaly does not threaten the child. But 2 doors wear out faster. And by adulthood, supportive therapy or surgery is sometimes needed. Less commonly, a defect such as a one-leaf valve occurs. Then the valve wears out even faster.

Another anomaly is congenital aortic valve stenosis. The semilunar cusps either fuse, or the valvular fibrous ring itself, to which they are attached, is excessively narrow. Then the pressure between the aorta and the ventricle is different. Over time, the stenosis increases. And interruptions in the work of the heart prevent the child from fully developing, it is difficult for him to do sports even in the school gym. A serious disruption of blood flow through the aorta at some point can lead to the sudden death of a child.

Acquired vices are the result of smoking, immoderate nutrition, sedentary and stressful lifestyle. Since everything is connected in the body, after 45-50 years, all minor ailments usually develop into diseases. The aortic valve of the heart wears out a little with old age, as it works constantly. Exploitation of the resources of your body, lack of sleep wear out these important parts of the heart faster.

aortic stenosis

What is stenosis in medicine? Stenosis means a narrowing of the lumen of a vessel. Aortic stenosis is a narrowing of the valve that separates the left ventricle of the heart from the aorta. Distinguish minor, moderate and severe. This defect can affect the mitral and aortic valves.

With a slight defect in the valve, a person does not feel any pain or other signal symptoms, because the increased work of the left ventricle will be able to compensate for poor valve performance for some time. Then, when the compensatory possibilities of the left ventricle are gradually exhausted, weakness and poor health begin.

The aorta is the main bloodstream. If the valve is broken, all vital organs will suffer from a lack of blood supply.

The causes of stenosis of the heart valves are:

1. Congenital valve disease: fibrous film, bicuspid valve, narrow ring.
2. A scar formed by connective tissue just below the valve.
3. Infective endocarditis. Bacteria that have fallen on the tissues of the heart change the tissue. Due to the colony of bacteria, connective tissue grows on the tissues and on the valves.
4. Deforming osteitis.
5. Autoimmune problems: rheumatoid arthritis, lupus erythematosus. Due to these diseases, connective tissue grows in the place where the valve is attached. Growths are formed on which calcium is deposited more. There is calcification, which we will recall later.
6. Atherosclerosis.

Unfortunately, in most cases, aortic stenosis is fatal if valve replacement is not done on time.

Stages and symptoms of stenosis

Doctors distinguish 4 stages of stenosis. At first, there is practically no pain or discomfort. Each stage has a set of symptoms. And the more serious the stage of development of stenosis, the faster the operation is needed.

• The first stage is called the compensation stage. The heart is still coping with the load. A deviation is considered insignificant when the valve clearance is 1.2 cm 2 or more. And the pressure is 10-35 mm. rt. Art. There are no symptoms at this stage of the disease.
• Subcompensation. The first symptoms appear immediately after exercise (shortness of breath, weakness, palpitations).
• Decompensation. It is characterized by the fact that the symptoms appear not only after exercise, but also in a calm state.
• The last stage is called terminal. This is the stage when strong changes have already occurred in the anatomical structure of the heart.

Symptoms of severe stenosis are:

• pulmonary edema;
• dyspnea;
• sometimes attacks of suffocation, especially at night;
• pleurisy;
• heart cough;
• pain in the chest area.

On examination, the cardiologist detects usually moist rales in the lungs during listening. The pulse is weak. Noises are heard in the heart, a vibration is felt created by the turbulence of blood flows.

Stenosis becomes critical when the lumen is only 0.7 cm 2 . The pressure is more than 80 mm. rt. Art. At this time, the risk of death is high. And even an operation to eliminate the defect is unlikely to change the situation. Therefore, it is better to consult a doctor in the subcompensatory period.

Development of calcification

This defect develops as a result of a degenerative process in the tissue of the aortic valve. Calcification can lead to severe heart failure, stroke, generalized atherosclerosis. Gradually, the leaflets of the aortic valve become covered with a calcareous growth. And the valve is calcified. That is, the valve flaps cease to close completely, and also open weakly. When a bicuspid aortic valve forms at birth, calcification renders it inoperative more quickly.

And also calcification develops as a consequence of disruption of the endocrine system. Calcium salts, when they do not dissolve in the blood, accumulate on the walls of blood vessels and on the valves of the heart. Or a kidney problem. Polycystic or kidney nephritis also lead to calcification.

The main symptoms will be:

• aortic insufficiency;
• expansion of the left ventricle (hypertrophy);
• interruptions in the work of the heart.

A person should take care of his health. Pain in the chest area and the increasing frequency of periodic attacks of angina pectoris should be a signal to undergo a cardiac examination. Without surgery for calcification, in most cases a person dies within 5-6 years.

Aortic regurgitation

During diastole, blood from the left ventricle flows into the aorta under pressure. This is how the systemic circulation begins. But with regurgitation, the valve "gives" blood back into the ventricle.

Valve regurgitation, or aortic valve insufficiency, in other words, has the same stages as valve stenosis. The causes of this condition of the valves are either an aneurysm, or syphilis, or the mentioned acute rheumatism.

Deficiency symptoms are:

• low pressure;
• dizziness;
• frequent fainting;
• swelling of the legs;
• broken heart rate.

Severe failure leads to angina pectoris and ventricular enlargement, as in stenosis. And such a patient also needs an operation to replace the valve in the near future.

valve seal

Stenosis can be formed due to the fact that endogenous factors cause the appearance of various growths on the valve leaflets. The aortic valve seals and begins to malfunction. The causes that led to the sealing of the aortic valve can be many untreated diseases. For example:

• Autoimmune diseases.
• Infectious lesions (brucellosis, tuberculosis, sepsis).
• Hypertension. As a result of prolonged hypertension, tissues become thicker and coarser. Therefore, over time, the gap narrows.
• Atherosclerosis is the clogging of tissues with lipid plaques.

Thickening of tissues is also a common sign of aging. Consolidation will inevitably result in stenosis and regurgitation.

Diagnostics

Initially, the patient must provide the doctor with all the necessary information for making a diagnosis in the form of an accurate description of the ailments. Based on the patient's medical history, the cardiologist prescribes diagnostic procedures in order to know additional medical information.

Required to be assigned:

• X-ray. The shadow of the left ventricle is enlarged. This can be seen from the arc of the contour of the heart. There are also signs of pulmonary hypertension.
• ECG. Examination reveals ventricular enlargement and arrhythmia.
• Echocardiography. On it, the doctor notices whether or not there is a seal of the valve flaps and a thickening of the walls of the ventricle.
• Probing cavities. The cardiologist must know the exact value: how much the pressure in the aortic cavity differs from the pressure on the other side of the valve.
• Phonocardiography. Noises are recorded during the work of the heart (systolic and diastolic murmur).
• Ventriculography. It is prescribed to detect mitral valve insufficiency.

With stenosis, the electrocardiogram shows disturbances in the rhythm and conduction of biocurrents. On the x-ray, you can clearly see signs of darkening. This indicates congestion in the lungs. It is clearly seen how dilated the aorta and left ventricle are. And coronary angiography shows that the amount of blood ejected from the aorta is less. It is also an indirect sign of stenosis. But angiography is done only for people over 35 years old.

The cardiologist also pays attention to symptoms that are visible even without devices. Paleness of the skin, Musset's symptom, Muller's symptom - such signs indicate that the patient most likely has aortic valve insufficiency. Moreover, the bicuspid aortic valve is more prone to insufficiency. The doctor must take into account congenital features.

What other signs can suggest a diagnosis to a cardiologist? If, when measuring pressure, the doctor notices that the upper one is much higher than normal, and the lower one (diastolic) is too low, this is a reason to refer the patient to echocardiography and radiographs. Extra noise during diastole, heard through a stethoscope, also does not bode well. This is also a sign of failure.

Treatment with drugs

For the treatment of insufficiency at the initial stage, drugs of the following classes can be prescribed:

• peripheral vasodilators, which include nitroglycerin and its analogues;
• diuretics are prescribed only for certain indications;
• calcium channel blockers, such as Diltiazem.

If the pressure is very low, nitroglycerin preparations are combined with Dopamine. But beta-blockers are contraindicated in case of aortic valve insufficiency.

Aortic valve replacement

Aortic valve replacement operations are now being carried out quite successfully. And with minimal risk.

During the operation, the heart is connected to a heart-lung machine. The patient is also given full anesthesia. How can a surgeon perform this minimally invasive operation? There are 2 ways:

1. The catheter is inserted directly into the femoral vein and ascends to the aorta against the flow of blood. The valve is fixed and the tube is removed.
2. The new valve is inserted through an incision in the chest on the left. An artificial valve is inserted, and it snaps into place, passing through the apical part of the heart, and is easily excreted from the body.

Minimally invasive surgery is suitable for those patients who have concomitant diseases, and it is impossible to open the chest. And after such an operation, the person immediately feels relief, as the defects are eliminated. And if there are no complaints about well-being, it can be discharged in a day.

It should be noted that artificial valves require constant intake of anticoagulants. Mechanical can cause blood clotting. Therefore, after the operation, Warfarin is immediately prescribed. But there are valves made of biological materials that are more suitable for humans. If a valve from the porcine pericardium is installed, then the drug is prescribed only for a few weeks after the operation, and then canceled, since the tissue takes root well.

Aortic balloon valvuloplasty

Sometimes aortic balloon valvuloplasty is prescribed. This is a painless operation according to the latest developments. The doctor controls all the actions taking place through special x-ray equipment. A catheter with a balloon is passed to the aortic orifice, then the balloon is placed in place of the valve and expanded. This eliminates the problem of valve stenosis.

To whom is the operation indicated? First of all, such an operation is performed on children with a congenital defect, when a unicuspid or bicuspid aortic valve is formed instead of a tricuspid one. It is indicated for pregnant women and people before another heart valve transplant.

After this operation, the recovery period is only from 2 days to 2 weeks. Moreover, it is transferred very easily and is suitable for people with poor health, and even children.

The patient is 45 years old. Survey. ECHOCG data: the width of the lumen of the aortic root is 30.0 mm, the excursion of the aortic walls is not reduced. Systolic divergence of the aortic valve leaflets 20.0 mm. the maximum diameter of the left atrium (DLP max.) = 30.0 mm. leaflets of the mitral valve move in antiphase speed E F anterior leaf 3.5 cm/sec; mitral-septal separation 6.0 mm. the maximum amplitude of the divergence of the mitral valve leaflets (RS MK) = 29.0 mm. The final diastolic size of the left ventricle (KDR LV) = 50.0 mm; The final systolic size of the left ventricle (CSR LV) = 32.0 mm. End diastolic volume of the left ventricle (EDV LV) = 118.0 ml, end systolic volume of the left ventricle (ESV LV) = 41.0 ml. Stroke volume (SV) = 77.0 ml…..

Questions:

1. Give an overall rating.
2. Assess indicators of central hemodynamics and global contractility of the left ventricle.
3. The chambers of the heart are not dilated, the valvular apparatus is intact, there are no signs of hypertrophy and local disorders of contractility of the left ventricular myocardium.
4. Indicators of global contractility of the left ventricle and central hemodynamics are within normal limits.

A 40-year-old patient has a history of: - rheumatoid arthritis in childhood. ECHO data. The width of the lumen of the aortic root is 28.0 mm. Excursion of the walls of the aorta is moderately reduced. Increased echogenicity of the aortic valve cusps, decreased mobility. In the upper part of the lumen of the aortic root, multiple additional echoes throughout the entire cardiac cycle. Systolic opening of the aortic valve leaflets = 8.0 mm. The maximum diameter of the left atrium (DLP max.) =42.0 mm. The leaflets of the mitral valve move in antiphase; the maximum amplitude of the divergence of the mitral valve leaflets (RS MK) = 28.0 mm. The final diastolic size of the left ventricle (ECD LV) = 51.0 mm; The final systolic size of the left ventricle (CSR LV) = 33.0 mm. End diastolic volume of the left ventricle (EDV LV) = 124.0 ml, Ejection fraction (EF) = 64.5%….

Questions:

1. Give a general assessment and indicate the pathology
2. What syndrome is the degree of severity of violations.

1. There is a change in the leaflets of the aortic valve with a decrease from the systolic divergence. There is a marked hypertrophy of the myocardium of the left ventricle with initial disturbances in diastolic function, a decrease in the elasticity of the hypertrophied left ventricle. The systolic pressure gradient between the left ventricle and the aorta is increased.

2. We are talking about the syndrome of stenosis of the aortic orifice of moderate severity, with preserved contractile function of the left ventricle.

The patient is 36 years old. History of rheumatoid arthritis in childhood. ECHOCG data: the width of the lumen of the aortic root is 28.0 mm, the excursion of the aortic walls is not reduced. Systolic divergence of the aortic valve leaflets 18.0 mm; the maximum diameter of the left atrium (DLP max.) = 50.0 mm. The leaflets of the mitral valve of increased echogenicity have a unidirectional "P" - figurative movement. The final diastolic size of the left ventricle (KDR LV) = 49.0 mm; The final systolic size of the left ventricle (CSR LV) = 34.0 mm. End diastolic volume of the left ventricle (EDV LV) = 113.0 ml, end systolic volume of the left ventricle (ESV LV) = 47.0 ml. Ejection fraction (EF) = 58.4%; Fraction of anteroposterior shortening ( D S) = 30.6%.. The thickness of the interventricular septum at the end of diastole (TMZhP cd) = 10.0 mm; excursion of the interventricular septum (E IVS) = 7.0 mm; thickness of the posterior wall of the left ventricle at the end of diastole (TZS cd) = 9.2 mm. excursion of the posterior wall of the left ventricle (EPSLV) = 9.0 mm ...

Questions:

1. What syndrome are you talking about? The degree of severity of violations.

1. Noticeable dilatation of the left atrium and right ventricle is noted. Hypertrophy of the myocardium of the right ventricle. Increased echogenicity of the mitral valve cusps, their deformation, decreased mobility. There is an increase in the linear velocity of the diastolic transmitral blood flow and its turbulent nature, the area of ​​the left atrioventricular orifice is markedly reduced. Doppler echocardiography of the outflow tract of the right ventricle and the orifice of the pulmonary artery revealed signs of pulmonary arterial hypertension. Relative insufficiency of the valve of the pulmonary artery.

2. We are talking about the syndrome of stenosis of the left atrioventricular orifice (mitral stenosis), moderate severity. In this case, mitral stenosis is probably of rheumatic origin.

The patient is 30 years old. History: 2 years ago, an abortion complicated by a septic condition and the development of infective endocarditis. After a course of inpatient treatment, there were no recurrences of infective endocarditis, which is constantly monitored by a general practitioner and a cardiologist.

ECHOCG data: the width of the lumen of the aortic root is 27.0 mm, the excursion of the aortic walls is normal. Systolic divergence of the aortic valve leaflets 19.0 mm. the maximum diameter of the left atrium (DLP max.) = 52.0 mm. mitral valve leaflets move in antiphase, making an “M” - figurative movement, there is a slight increase in their echogenicity and thickening, to a greater extent, of the anterior leaflet, where there is an area of ​​calcification closer to the base of the leaflet ...

Questions:

1. Give a general assessment and indicate the pathology.

1. There is dilatation of the left atrium and left ventricle. Signs of volume load on the left ventricle (increased excursion of its walls during dilatation of the cavity). Signs of hypertrophy of the myocardium of the left ventricle. There are signs of organic changes in the aortic cusps of the aortic valve, without violations of their mobility. Doppler echocardiography revealed signs of grade IV mitral regurgitation.

2. We are talking about mitral insufficiency syndrome (severe mitral insufficiency). Mitral regurgitation was caused by infective endocarditis.

The patient is 40 years old. Complaints about sensations of pulsation in the head, neck. Pain in the region of the heart (behind the sternum) of a pressing nature during physical exertion, passing after a few minutes at rest. The above complaints appeared 2 years ago. Previously, he considered himself practically healthy. Examination revealed a positive Wasserman reaction ( RW).

ECHOCG data: the width of the lumen of the aortic root is 45.0 mm, the excursion of the aortic walls is increased. The systolic divergence of the aortic valve leaflets is 22.0 mm, the aortic valve leaflets are mobile, their echogenicity is normal; there is a systolic non-closure of the aortic valve leaflets, the maximum diameter of the left atrium (LLA max.) = 37.0 mm., the mitral valve leaflets move in antiphase, making an "M" -shaped movement, the systolic divergence of the mitral valve leaflets is 28.0 mm.

Questions:

1. Give a general description of the pathology.
2. What syndrome are we talking about?

1. There is an expansion of the lumen of the aortic root, with a relatively small change in the cusps of the aortic valve, the mobility of which is not reduced, but there are signs of their incomplete closure in diastole. There is a markedly pronounced dilatation of the left ventricle, hypertrophy of its myocardium, signs of a volume load on the left ventricle, diastolic trembling of the anterior leaflet of the mitral valve indicates a mechanical effect on the leaflet of the jet penetrating into the diastole from the aorta into the left ventricle. Doppler-ECHO-KG study revealed pronounced signs of aortic regurgitation.

2. We are talking about the syndrome of severe aortic valve insufficiency. Existing complaints, including angina attacks, are associated with hemodynamic disturbances against the background of this syndrome. The cause of aortic insufficiency is presumably syphilitic meso-aortitis.

The patient is 30 years old. Complaints of shortness of breath, palpitations during physical exertion, heaviness in the right hypochondrium, pastosity of the legs. In history, he was repeatedly treated for drug addiction in narcological hospitals; 2 years ago he had infective endocarditis. ECHOCG data: the width of the lumen of the aortic root is 35.0 mm, the excursion of the aortic walls is normal. Systolic divergence of the aortic valve leaflets 19.0 mm. Aortic valve leaflets without visible changes; the maximum diameter of the left atrium (DLP max.) = 35.0 mm. leaflets of the mitral valve move in antiphase, making "M" - shaped movement, speed E Fanterior leaf 3.6 cm/sec; the maximum amplitude of the divergence of the mitral valve leaflets (RS MK) = 29.0 mm ...

Questions:

1. Give a general description of pathological changes.
2. What syndrome are we talking about? The degree of severity of violations.

1. There are changes in the right parts of the heart. Dilatation of the right ventricle and right atrium. Signs of volume load on the right ventricle, hypertrophy of its myocardium. Signs of severe tricuspid regurgitation. Indirect signs of increased pressure in the right chambers of the heart and inferior vena cava. Signs of penetration of the regurgitant jet into the inferior vena cava and hepatic veins. Indirect signs of organic changes in the leaflets of the tricuspid valve with the preservation of their mobility.

2. We are talking about the tricuspid valve insufficiency syndrome (significantly pronounced insufficiency). The cause of isolated tricuspid insufficiency in this case is probably a previous infective endocarditis.

The patient is 28 years old. Complaints of stabbing pains in the apex of the heart, long-term or short-term (less than 1 minute), without a clear connection with physical activity. Occasionally "interruptions" in the work of the heart, discomfort in the precordial region. Received for examination.

ECHOCG data: the width of the lumen of the aortic root is 27.0 mm, the excursion of the aortic walls is not reduced. Systolic divergence of the aortic valve leaflets 21.0 mm. Aortic valve leaflets with normal echogenicity. The maximum diameter of the left atrium (LLA max.) = 32.0 mm. mitral valve leaflets move in antiphase speed, making "M" - figurative movement. Speed ​​E F anterior leaf 3.7 cm/sec; mitral-septal separation 5.0 mm. The maximum amplitude of the divergence of the mitral valve leaflets (RS MK) = 29.0 mm ...

Questions:

1. Give an overall rating.
2. What syndrome are we talking about? The degree of severity of violations.

1. There is a change in the leaflets of the mitral valve with systolic sagging (deflection) of the anterior leaflet into the cavity of the left atrium. There are signs of an organic change in the leaflets of the mitral valve without disturbing their opening. Signs of mitral regurgitation were revealed. Otherwise, the chambers of the heart were not dilated, and no signs of functional impairment were detected.

2. We are talking about the syndrome of prolapse (prolapse) of the mitral valve. In this case, grade II mitral valve prolapse with grade II mitral regurgitation and evidence of myxomatous leaflet degeneration.

Incomplete closure of the aortic valve during diastole, resulting in backflow of blood from the aorta into the left ventricle. Aortic insufficiency is accompanied by dizziness, fainting, chest pain, shortness of breath, frequent and irregular heartbeat. To diagnose aortic insufficiency, chest X-ray, aortography, echocardiography, ECG, MRI and CT of the heart, cardiac catheterization, etc. are performed. Treatment of chronic aortic insufficiency is carried out conservatively (diuretics, ACE inhibitors, calcium channel blockers, etc.); in severe symptomatic cases, aortic valve repair or replacement is indicated.

General information

Aortic insufficiency (aortic valve insufficiency) is a valvular defect in which during diastole the semilunar leaflets of the aortic valve do not completely close, resulting in diastolic regurgitation of blood from the aorta back into the left ventricle. Among all heart defects, isolated aortic insufficiency is about 4% of cases in cardiology; in 10% of cases, aortic valve insufficiency is combined with other valvular lesions. The vast majority of patients (55-60%) have a combination of aortic valve insufficiency and aortic stenosis. Aortic insufficiency is 3-5 times more common in males.

Causes of aortic insufficiency

Aortic insufficiency is a polyetiological defect, the origin of which may be due to a number of congenital or acquired factors.

Congenital aortic insufficiency develops when there is a one-, two-, or four-leaf aortic valve instead of a tricuspid one. The causes of aortic valve defect can be hereditary diseases of the connective tissue: congenital pathology of the aortic wall - aortoannular ectasia, Marfan syndrome, Ehlers-Danlos syndrome, cystic fibrosis, congenital osteoporosis, Erdheim's disease, etc. In this case, incomplete closure or prolapse of the aortic valve usually occurs.

The main causes of acquired organic aortic insufficiency are rheumatism (up to 80% of all cases), septic endocarditis, atherosclerosis, syphilis, rheumatoid arthritis, systemic lupus erythematosus, Takayasu's disease, traumatic valve injuries, etc. Rheumatic damage leads to thickening, deformation and wrinkling of the valve leaflets aorta, resulting in their complete closure during diastole. Rheumatic etiology usually underlies the combination of aortic insufficiency with mitral valve disease. Infective endocarditis is accompanied by deformity, erosion, or perforation of the leaflets, causing a defect in the aortic valve.

The occurrence of relative aortic insufficiency is possible due to the expansion of the fibrous ring of the valve or the lumen of the aorta in arterial hypertension, aneurysm of the sinus of Valsalva, exfoliating aortic aneurysm, ankylosing rheumatoid spondylitis (Bekhterev's disease), and other pathologies. In these conditions, separation (divergence) of the aortic valve leaflets during diastole can also be observed.

Hemodynamic disorders in aortic insufficiency

Hemodynamic disorders in aortic insufficiency are determined by the volume of diastolic blood regurgitation through the valve defect from the aorta back to the left ventricle (LV). In this case, the volume of blood returning to the LV can reach more than half of the value of cardiac output.

Thus, in aortic insufficiency, the left ventricle during diastole is filled both as a result of blood flow from the left atrium and as a result of aortic reflux, which is accompanied by an increase in diastolic volume and pressure in the LV cavity. The volume of regurgitation can reach up to 75% of the stroke volume, and the end diastolic volume of the left ventricle can increase to 440 ml (at a rate of 60 to 130 ml).

The expansion of the cavity of the left ventricle contributes to the stretching of the muscle fibers. To expel the increased volume of blood, the force of contraction of the ventricles increases, which, in a satisfactory state of the myocardium, leads to an increase in systolic ejection and compensation for altered intracardiac hemodynamics. However, long-term work of the left ventricle in the hyperfunction mode is invariably accompanied by hypertrophy and then dystrophy of cardiomyocytes: a short period of tonogenic LV dilatation with an increase in blood outflow is replaced by a period of myogenic dilatation with an increase in blood flow. The end result is mitralization of the defect - relative insufficiency of the mitral valve, due to LV dilatation, dysfunction of the papillary muscles and expansion of the fibrous ring of the mitral valve.

In conditions of compensation of aortic insufficiency, the function of the left atrium remains unimpaired. With the development of decompensation, there is an increase in diastolic pressure in the left atrium, which leads to its hyperfunction, and then to hypertrophy and dilatation. Stagnation of blood in the system of vessels of the pulmonary circulation is accompanied by an increase in pressure in the pulmonary artery, followed by hyperfunction and hypertrophy of the myocardium of the right ventricle. This explains the development of right ventricular failure in aortic disease.

Classification of aortic insufficiency

To assess the severity of hemodynamic disorders and compensatory capabilities of the body, a clinical classification is used that distinguishes 5 stages of aortic insufficiency:

• I - stage of full compensation. Initial (auscultatory) signs of aortic insufficiency in the absence of subjective complaints.
• II - stage of latent heart failure. A moderate decrease in exercise tolerance is characteristic. ECG revealed signs of hypertrophy and volume overload of the left ventricle.
• III - stage of subcompensation of aortic insufficiency. Typical anginal pain, forced restriction of physical activity. On the ECG and radiographs - left ventricular hypertrophy, signs of secondary coronary insufficiency.
• IV - stage of decompensation of aortic insufficiency. Severe shortness of breath and attacks of cardiac asthma occur at the slightest exertion, an enlarged liver is determined.
• V - terminal stage of aortic insufficiency. It is characterized by progressive total heart failure, deep dystrophic processes in all vital organs.

Symptoms of aortic insufficiency

Patients with aortic insufficiency in the stage of compensation do not report subjective symptoms. The latent course of the defect can be long - sometimes for several years. The exception is acutely developed aortic insufficiency due to exfoliating aortic aneurysm, infective endocarditis, and other causes.

Symptoms of aortic insufficiency usually manifest with sensations of pulsation in the vessels of the head and neck, increased cardiac tremors, which is associated with high pulse pressure and increased cardiac output. Sinus tachycardia, characteristic of aortic insufficiency, is subjectively perceived by patients as a rapid heartbeat.

With a pronounced valve defect and a large amount of regurgitation, brain symptoms are noted: dizziness, headaches, tinnitus, visual disturbances, short-term fainting (especially with a quick change from horizontal to vertical).

In the future, angina pectoris, arrhythmia (extrasystole), shortness of breath, increased sweating join. In the early stages of aortic insufficiency, these sensations are disturbing, mainly during exercise, and later occur at rest. Attachment of right ventricular failure manifests itself as swelling in the legs, heaviness and pain in the right hypochondrium.

Acute aortic insufficiency proceeds as pulmonary edema, combined with arterial hypotension. It is associated with sudden left ventricular volume overload, increased LV end-diastolic pressure, and decreased stroke output. In the absence of special cardiac surgical care, mortality in this condition is extremely high.

Diagnosis of aortic insufficiency

Physical findings in aortic insufficiency are characterized by a number of typical features. On external examination, the pallor of the skin draws attention, in the later stages - acrocyanosis. Sometimes external signs of increased pulsation of the arteries are detected - “carotid dance” (pulsation visible to the eye on the carotid arteries), Musset’s symptom (rhythmic nodding of the head to the beat of the pulse), Landolfi’s symptom (pulse of the pupils), “Quincke’s capillary pulse” (pulsation of the vessels of the nail bed ), Muller's symptom (pulsation of the tongue and soft palate).

Typically visual definition of the apex beat and its displacement in the VI-VII intercostal space; pulsation of the aorta is palpated behind the xiphoid process. Auscultatory signs of aortic insufficiency are characterized by diastolic murmur on the aorta, weakening of I and II heart sounds, "accompanying" functional systolic murmur on the aorta, vascular phenomena (Traube's double tone, Durozier's double murmur).

Instrumental diagnosis of aortic insufficiency is based on the results of ECG, phonocardiography, x-ray studies, echocardiography (TEE), cardiac catheterization, MRI, MSCT. Electrocardiography reveals signs of left ventricular hypertrophy, with mitralization of the defect - data for left atrial hypertrophy. With the help of phonocardiography, altered and pathological heart murmurs are determined. An echocardiographic study reveals a number of characteristic symptoms of aortic insufficiency - an increase in the size of the left ventricle, an anatomical defect, and functional failure of the aortic valve.

Signs of inoperability are an increase in LV diastolic volume up to 300 ml; ejection fraction 50%, end diastolic pressure about 40 mm Hg. Art.

Forecast and prevention of aortic insufficiency

The prognosis of aortic insufficiency is largely determined by the etiology of the defect and the amount of regurgitation. With severe aortic insufficiency without decompensation, the average life expectancy of patients from the moment of diagnosis is 5-10 years. In the decompensated stage with symptoms of coronary and heart failure, drug therapy is ineffective, and patients die within 2 years. Timely cardiac surgery significantly improves the prognosis of aortic insufficiency.

Prevention of the development of aortic insufficiency consists in the prevention of rheumatic diseases, syphilis, atherosclerosis, their timely detection and full treatment; clinical examination of patients at risk for the development of aortic disease.