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  • Aortic insufficiency( aortic valve insufficiency) - Causes, symptoms and treatment. MF.

    Causes and symptoms of aortic insufficiency
    Diagnosis, degree of aortic valve failure
    Treatment
    Lifestyle with
    disease Complications and prognosis

    Aortic valve is a kind of connective tissue damper consisting of three valves and located in the mouth of the largest blood vessel of the body - the aorta. Its function is to differentiate between the cavities of the left ventricle and the aorta. After the outflow of blood into the aorta from the ventricle at the time of its relaxation, the valve flaps tightly closed, facilitating the movement of blood towards the arteries of a smaller caliber and preventing backflow to the left ventricular cavity. With a pathological change in the structure or mobility of the valves, their function is violated, which leads to the formation of aortic valve defects.

    These defects include stenosis and aortic valve insufficiency, with isolated aortic insufficiency occurring in only 4% of cases among heart defects.

    Thus, aortic insufficiency is an acquired heart defect, characterized by incomplete closure of valve flaps at the time of diastole( relaxation) of the left ventricle, a reverse transfer of blood into it and a decrease in the volume of blood discharged into the aorta with a corresponding decrease in blood flow in the arteries and capillaries of all body tissues.

    Causes of aortic insufficiency

    The main cause of the disease, as well as other acquired defects, is heart damage as a result of acute rheumatic fever( rheumatic fever).At the same time, atherosclerosis, bacterial endocarditis, long-term arterial hypertension, aortic aneurysm, including its acute dissection, systemic lupus erythematosus, rheumatoid arthritis, may lead to aortic insufficiency, especially if the valve structure predisposes to developmentin it changes, for example, congenital pathology - bicuspid aortic valve. A very rare cause may be damage to the valve resulting from syphilis.

    Symptoms of aortic valve failure

    As with aortic valve stenosis, with its insufficiency or a combination of these defects, the clinical picture may not manifest itself for decades if the malformation occurred at a young age and is characterized by not very pronounced regurgitation( reverse blood flow to the left ventricle).

    In the compensation phase of ( heart failure is absent), the symptoms do not bother the patient due to the development of compensatory mechanisms on the heart, for example, an increase in the strength and frequency of contractions of the left ventricle, which for a long time is able to maintain adequate blood flow in the capillaries of vital organs( brain, liver, kidneys, etc.)

    In the stage of subcompensation of ( latent heart failure), patients are concerned about complaints of heart palpitations, dyspnoea with physical exertion, feelings witha few strokes of the heart, strengthening in the position on the left side, dizziness, a tendency to fainting with a change in body position, general weakness and increased fatigue.

    In the stage of decompensation of ( obvious heart failure), the above complaints appear in the state of ordinary household activity, and often at rest. Also, complaints are attached to the retrosternal pressing pains, which are given to the left arm and shoulder blade. This condition is called angina pectoris, which develops as a result of the fact that hypertrophied( enlarged and stretched by an increased volume of blood returning back), the left ventricle does not receive enough oxygen from the blood flowing through the coronary( own heart) arteries. Shortness of breath at this stage can be a formidable symptom of cardiac( "cardiac") asthma, which is a manifestation of pulmonary edema.

    Patient with swelling experiences difficulty, bubbling breath, inability to breathe when lying down;there is a choking cough with frothy, bloody sputum. All these manifestations are indicative of developing left ventricular heart failure.

    In the stage of severe decompensation of ( severe heart failure), right ventricular failure is also associated with left ventricular failure, as the right ventricle experiences certain difficulties for expelling blood to the overcrowded pulmonary arteries. As a result, there is an overload of the right heart, which clinically manifests pronounced swelling of the lower limbs, face, hands, whole body, accumulation of fluid in the abdominal cavity and enlarged abdomen, heaviness and pain in the right upper quadrant due to increased blood filling and enlarged liver.

    In the terminal stage of , the patient, as a result of pathological processes in all organs and the attachment of complications, develops permanent irreversible metabolic disturbances and dystrophic changes in organs and tissues, which leads to a fatal outcome. The human heart is so exhausted that it simply can not adequately circulate blood throughout the body.

    Diagnosis of aortic insufficiency

    A doctor may still be at the stage of clinical examination to suspect aortic insufficiency.

    Attention is drawn to the following symptoms:
    - general pallor of the patient( in comparison with mitral defects, cyanosis, or blue skin color, is not determined until the terminal stage);
    - friendly with a pulse of saturation of color of throat and tonsils( Müller's symptom) and nail bed - a capillary pulse( Quincke symptom).These symptoms are associated with changes in the blood filling of the smallest capillaries of the skin and mucous membranes in the stage of systole and diastole of cardiac contraction, when part of the blood expelled from the heart into the systole and imparts a rich color to the skin and mucous membrane, returns back to the diastole, resulting in a reddish shade of mucous throat orThe nail bed turns pale, and with the next heart beat again acquires a red tint;
    - "dancing carotid" - pulsating movements of the common carotid arteries on the neck;
    - visible pulsation of the aortic arch in the pit above the jugular sternum;
    - a symptom of Musset - friendly with the pulse of the swinging of the head;
    - when measuring the pulse, its high and fast rhythm is revealed;
    - when measuring blood pressure, systolic( "upper") pressure can be increased, and diastolic( "lower") pressure is sharply reduced;
    - during auscultation( listening) of the chest, a gentle( not coarse, in contrast to stenosis) noise during diastole-relaxation of the ventricle is determined, as well as a weakening of the second heart tone( absent or muffled sound of the aortic valve slamming).Wet or dry rales in the lungs may be heard;
    - with palpation( probing) of the abdominal cavity organs, the dense edges of the enlarged liver can be determined.

    If a physician suspects diagnosis of the aortic valve flaw during the examination and familiarization with complaints and the history of the patient's disease, he appoints additional methods of laboratory and instrumental diagnostics to confirm the diagnosis. These methods include:

    - general blood and urine tests, biochemical and immunological examination of the blood determine the presence of rheumatic process in the body, impaired liver and kidney function, autoimmune diseases - rheumatoid arthritis, systemic lupus erythematosus.
    - ECG shows marked hypertrophy of the left ventricle, and later of the right heart, myocardial ischemia, deviation of the electrical axis of the heart to the left, atrial and ventricular extrasystoles are recorded.
    - the chest radiograph shows an enlargement of the left heart.
    - Echocardiography( ECHO - KG) - a method of visualization of internal structures of the heart and large vessels with the help of ultrasonic waves. It allows to clarify the anomalies of the structure of the valve, the structure and mobility of its valves, to determine the presence of regurgitation( reverse blood flow to the left ventricle), to measure the shock volume and the fraction of the left ventricular ejection and other important indicators. Depending on the severity of regurgitation, aortic insufficiency can be divided into degrees:

    1 degree - initial aortic insufficiency - no more than 30% of the blood returns from the aorta to no more than 30% of the blood from all blood expelled into the aorta from the left ventricle for one cardiac contraction;the regurgitation jet reaches no more than 5 mm from the aortic valve to the left ventricular cavity;
    2 degree - moderate insufficiency - volume of regurgitation 30 - 50%, length of blood stream - 5-10 mm;
    3 degree - severe insufficiency - the volume of regurgitation is more than 50%, the return flow of blood is 10 mm or more in length.

    In the figure, the arrow indicates the return of blood to the left ventricle( regurgitation)

    - in diagnostic and unclear cases, a transesophageal echocardiogram - CG, stress ECHO - KG( ultrasound of the heart with physical activity), coronary angiography( CAG) - radiocontrast study of coronary vesselsfinding out their passableness for the decision of a question on carrying out of an operative intervention simultaneously on the valve of an aorta and on coronary arteries.

    Treatment of aortic valve deficiency

    As in the treatment of other heart defects, medical and surgical methods of treatment are used in the treatment of this disease.

    Pharmacological methods include prescribing the following pharmacological groups: peripheral vasodilators( nitroglycerin and its analogs, apressin, adelphan and others), antihypertensive agents( ACE inhibitors - perindopril, captopril, etc.), calcium channel blockers( verapamil, diltiazem, nifedipine and others), according to indications of diuretics( diuretics - lasix, indapamide, etc.).

    In order to prevent the development of hypotension( a sharp decrease in blood pressure) in acute aortic insufficiency( pulmonary edema in patients with aortic dissecting aneurysm, for example), these drugs are prescribed in combination with dopamine.

    Drugs that reduce heart rate( beta-blockers) are contraindicated, since an increase in the heart rate is a compensatory mechanism in the heart to maintain systemic blood flow at the proper level.

    Surgical methods of treatment use aortic valve replacement with replacement with a mechanical or biological implant. In the case of a patient with acute aortic insufficiency and exfoliating aneurysm of the aortic root, an operation is performed on the transplantation of the valve and the root, and the pulmonary artery of the patient itself can serve as the implant.

    Lifestyle in aortic insufficiency

    In addition to medical and surgical methods of treatment, a very important role in maintaining the overall level of health in this pathology plays a lifestyle. From the main recommendations can be identified the following:

    1. Mode. A patient with aortic defect should observe a rational mode of work and rest, rest more, sleep enough, walk more often in the air, eliminate physical stress and limit stress.
    2. Diet. It is necessary to organize a correct and clear mode of eating, to eat more fruits, vegetables, low-fat varieties of meat and fish, dairy products;limit consumption of table salt and liquid;Exclude sharp, salty, fatty and fried dishes, spices, chocolate, coffee, alcohol.
    In the cardiological hospital, a medical table №10 is used.
    3. The ability to work can be saved for a long time in the absence of symptoms from the heart, but the patient who is diagnosed with this diagnosis should be informed to the attending physician about the nature of the work activity, in particular, the presence of significant physical and psychoemotional loads.
    4. The patient should visit the clinic on a regular basis, with the fulfillment of all the prescriptions of the doctor, especially those related to laboratory and instrumental examination methods.
    5. At the onset of pregnancy, interruption is indicated in case of significant clinical manifestations of heart failure. In the absence of symptoms or minimal changes in hemodynamics by ultrasound of the heart, pregnancy can be prolonged. For each patient, the issue of maintaining pregnancy is decided individually.

    Complications of aortic insufficiency

    In the absence of medical or surgical treatment, the patient may develop complications such as acute myocardial infarction, bacterial endocarditis( inflammation of the valvular apparatus of the heart caused by subsidence of microorganisms on already changed rheumatism or atherosclerosis valves), pulmonary edema, cardiac rhythm disturbances( atrial fibrillation, atrial and ventricular extrasystole, ventricular fibrillation), thromboembolic complications( thrombus transfers heart into the vessels of the lungs, brain, intestine, with the development of heart attacks and strokes in these organs)

    If the patient is referred for surgery, the physician should warn him about a certain degree of operational risk and operational mortality. In the case of operations on the aortic valve, these risks are relatively small, which allows a very high survival rate after cardiac surgery. But nevertheless there is a small probability of development of postoperative complications, for example, a thrombus formation on an artificial valve with a detachment of thrombi, bacterial endocarditis, melting of a biological implant. Preventive maintenance of complications is the lifelong reception of warfarin, curantil, clopidogrel and other anticoagulants, the timely administration of antibiotics, as well as the prevention of repeated rheumatic attacks.

    Forecast

    Without treatment for some time in the compensation stage, the prognosis for life and work is favorable. But after the onset of clinical manifestations, the disease without treatment is rapidly progressing, and most patients die in the first two to four years from the onset of heart failure and angina. The surgical method of treatment in combination with taking medications allows prolonging the life of the patient and improving the quality of life, that is, after treatment, the prognosis is favorable.

    Doctor therapist Sazykina O.Yu.