Heart defects acquired

Heart defects are acquired - lesions of the heart valve (valves), the valves of which are unable to fully open (stenosis) the valve opening or to close (valve failure) or both (combined defect).

Etiology and pathogenesis. Etiology of stenosis and combined defect rheumatic, valve insufficiency - usually rheumatic, rarely septic, atherosclerotic, traumatic, syphilitic. Stenosis is formed due to cicatricial fusion or cicatricial rigidity of valve flaps, sub-valvular structures; Failure of the valve - due to their destruction, damage or scar deformation. Affected valves form an obstacle to the passage of blood - anatomical in stenosis, dynamic in insufficiency. The last is that part of the blood, although it passes through the hole, but returns to the next phase of the cardiac cycle. To the effective volume is added "parasitic", making a pendulum movement on both sides of the affected valve. Significant valve failure is complicated by relative stenosis (due to increased blood volume). The obstruction of the passage of blood leads to overload, hypertrophy and the expansion of the overlying chambers of the heart. Expansion is more significant when the valve is inadequate, when the overlying chamber is stretched by additional blood. With stenosis of the atrioventricular orifice, the filling of the underlying chamber (left ventricle with mitral stenosis, right at tricuspid) is decreased; Hypertrophy and expansion of the ventricle. When the valve is insufficient, the filling of the corresponding ventricle is increased, the ventricle is expanded and hypertrophied. Difficulty in the work of the heart due to improper functioning of the valve and the dystrophy of hypertrophied myocardium leads to the development of heart failure (see).

The diagnosis should contain an indication of the etiology (proven or probable) of the defect, its shape, the presence of heart failure (if it exists, then its degree). It should be borne in mind that the anamnestic indications for the etiology of the defect - rheumatism, sepsis, syphilis, trauma, are not always clear enough, and indications of frequent angina are not very specific.

Actually the vice manifests itself almost exclusively by acoustic signs. Echocardiographic study allows you to detect stenosis and evaluate its degree; In the sectoral scanning mode, the degree of mitral stenosis (the area of ​​the left atrioventricular orifice) is determined with great accuracy. The insufficiency of the valves is judged by indirect signs - dilatation and volumetric overloading of chambers. Dopplercardiographic examination reveals a reverse blood flow (valve failure).

Treatment of the actual blemish can only be surgical. To clarify the indications for such treatment, a timely consultation of a cardiosurgeon specialist is necessary. Conservative therapy is reduced to the prevention and treatment of relapse of the main process and complications, to the treatment and prevention of heart failure, as well as violations of the heart rhythm. Of great importance are timely and adequate professional orientation and employment of the patient.

Mitral defect - mitral valve damage, accompanied by difficulty in passing blood from the small circle to the large one at the level of the left atrioventricular orifice. Heart failure manifests itself mainly in the form of congestive left ventricular, then - and right ventricular failure.

Symptoms, course. With increasing pressure in the small circle, complaints of dyspnoea appear (more pronounced with stenosis), palpitation, coughing, with the increase of right ventricular failure - fluid retention and pain in the right hypochondrium. On examination and palpation, signs of congestive right ventricular failure may be found, in pronounced cases a characteristic cyanotic blush of the cheeks and lips is noticeable. Often there is an extrasystole. Atrial fibrillation with insufficiency is not less common than with stenosis (with the same severity of the defect). Hypertrophy of the right ventricle is manifested by an intensified epigastric heart impulse. With a significant expansion of the cavity of the right ventricle, systolic murmur of relative tricuspid insufficiency appears. It can be loud and spread to the apex of the heart, which often leads to overdiagnosis of mitral insufficiency. Despite the expansion of the pulmonary artery, due to the overload of the small circle, systolic murmur of relative pulmonary stenosis may occur. This noise is often interpreted as a mitral noise (due to the coincidence of listening zones for these noises). With high pulmonary hypertension, a diastolic increase in relative pulmonary insufficiency (Graham-Still noise) may appear at the left edge of the sternum. X-ray revealed an increase in the left atrium and stagnant changes in the lungs. An increase in the right chambers of the heart leads to an expansion of the cardiac shadow not so much to the right as to the left. However, in patients with mitral insufficiency, the expansion of the cardiac shadow to the left may be due to an increase in the left ventricle. Attachment of secondary pulmonary hypertension leads to a significant expansion of the shadow of the main branches of the pulmonary artery. Electrocardiography usually recognizes hypertrophy of the left atrium. "Certain" ECG signs of right ventricular hypertrophy appear late and unstable; "Possible" indications for hypertrophy of the right ventricle are unreliable.

Diagnosis. It is necessary to have acoustic signs of stenosis of the valve opening or valve failure. For hemodynamically significant mitral malformation necessarily increase the shade of the left atrium. Mitral stenosis and mitral valve insufficiency are diagnosed not only on the basis of acoustic signs specific for each of these defects, but also with the help of radiography and echocardiography.

Differential diagnosis: exclude other acquired and congenital malformations, in particular atrial septal defect (three-member rhythm, similar hemodynamic disorders), myocarditis, myocardiopathy, pericarditis, coronary heart disease, pulmonary heart failure in chronic obstructive pulmonary diseases, primary pulmonary hypertension , Thyrotoxicosis, as well as prolapse of the mitral valve (see). The peculiar form of the defect is the mitral valve prolapse syndrome.

The prognosis and ability to work is determined by the degree of heart failure.

Mitral stenosis. Specific acoustic signs: 1 diastolic noise at the apex, represented by two components: low-frequency, "rumbling" proto-diastolic ("mesodiastolic") and growing to 1 tone presystolic or one of them; 2) high-frequency "snapping" protodiastolic extrathone - mitral click. Characterized by increased ("clapping")! Tone, forming together with the second tone and a mitral click the three-term "quail's rhythm". One of the two diastolic noises is often taken for systolic, which leads to overdiagnosis of mitral insufficiency.

With a slight narrowing of the left atrioventricular orifice (an opening area of ​​more than 1.5 cm2), dyspnea appears only with significant loads (1 WHO functional class). Attacks of suffocation and orthopnea are not present. The heart is not dilated. Diastolic (predominantly presystolic) noise may be weak. With moderate stenosis (area of ​​the atrioventricular orifice from 1 to 1.5 cm2), dyspnea appears with less significant loads (II functional class WHO), attacks of suffocation are uncharacteristic. Diastolic noise (both components, with atrial fibrillation - only proto-diastolic) is intense. The tip often has a diastolic tremor. Expansion of the heart to the left can be significant, there is usually no sign of secondary pulmonary hypertension. Progressing heart failure may develop with moderate stenosis, but not as quickly and inevitably as in the case of abrupt stenosis. For acute stenosis (the area of ​​the atrioventricular aperture is 1 cm2 or less), shortness of breath is characterized with insignificant and minimal loads (AND - WHO functional classes), asthma attacks, orthopnea. Often there is a significant expansion of the heart to the left, as well as signs of high secondary pulmonary hypertension. Diastolic murmur is represented mainly or exclusively by the proto-diastolic component. In the most severe stenosis, there is no diastolic tremor, diastolic murmur is weak or absent. In these cases, the acoustic manifestation of stenosis is the "quail rhythm" with systolic murmur of relative tricuspid insufficiency. But with gross deformations of the valve flaps (due to fibrosis and calcification) clapping! Tone ceases to be heard, as well as "the rhythm of the quail." A sharp mitral stenosis predetermines the development of progressive heart failure.

Indications for surgical treatment arise in patients with severe stenosis or with moderate stenosis in the progressing stages. Untimely sending a patient to commissurotomy is a medical error.

Insufficient mitral valve. The key to the diagnosis is the ability to recognize a specific mitral systolic murmur - an indispensable symptom of this defect. Early noise is layered on I tone (or replaces it), high-frequency, different timbre. The noise at the apex of the heart is heard, it is characteristic of spreading to the left, it can extend to the precordial region. Mitral systolic murmur should be distinguished from aortic and tricuspid (see below), as well as from the noise of relative pulmonary stenosis. The latter differs from the mitral with the following features: 1) localization in the Botkin-Erba zone (can be conducted to the apex); 2) "blowing lip" timbre, approaching the sound of the consonant "ff-ff"; 3) spindle-shaped configuration; 4) the fact that it does not layer on the tone (FKG control).

With insignificant insufficiency there are no complaints. Systolic noise can be short, localized in a restricted area near the apex. !! Tone is often saved. There is no pronounced amplification of the apical impulse. The heart is not significantly enlarged. With moderate deficiency, complaints of palpitations, increased fatigue, mild dyspnoea, fluid retention may appear. Epistemologically marked the pastosity of the shins. The liver is not enlarged. Almost necessarily palpated a slow, "sticking" true strengthened apical impulse (distinguished from the characteristic for stenosis "jerky" push - the palpation equivalent of the fading 1 tone). The heart is always considerably widened to the left. Noise occupies the entire systole. The tone is usually weakened. Often found III tone. With a significant mitral valve insufficiency, the symptoms of heart failure can be expressed right up to the signs of edematous degeneration, but may remain subtle. Tone I at the tip, as a rule, there is no systolic murmur intensive. Usually, an intensive pathological III tone is found. A significant increase in the left ventricle is radioliologically detected, not so much by the expansion of the heart to the left, as by extension to the posterior. For the diagnosis of severe mitral insufficiency, only "certain" ECG signs of left ventricular hypertrophy with a negative asymmetric ("secondary type") T wave in the left thoracic leads are important. "Amplitude" ECG indications for "possible" left ventricular hypertrophy are unreliable.

In case of a combined mitral malignancy, one should be guided by such signs of essential mitral valve insufficiency as a significant extension of the heart to the left and a strengthened apical impulse. If there are no such signs in a patient with heart failure (stage IIA or more), then the severity of the condition is determined by the presence of pronounced mitral stenosis.

Aortic defect. Symptoms, flow are determined by the form of the defect (aortic stenosis or aortic valve insufficiency) and the severity of hemodynamic disorders.

Aortic stenosis can be rheumatic (atherosclerotic) or congenital. The inadequacy of the discharge of blood into the aorta can lead to insufficiency of the cerebral and coronary blood circulation (first of all, under load and transition to the vertical position), which manifests itself as subjective and objective signs. The diagnosis is based on the presence of specific systolic murmur. His signs: 1) presence on the basis of the heart - in the second intercostal space to the right of the sternum (to the left of the sternum at the Botkin point and even at the apex the noise can be as or more intense); 2) conducting on carotid arteries, in the jugular and subclavian fossa; 3) a characteristic "rough" timbre; 4) spindle-shaped configuration; 5) the noise does not layer on the I tone and never reaches the aortic component of the P tone; 6) the noise abruptly weakens or disappears after a short diastole (arrhythmia, tachycardia), amplified after a long one. Characteristic splitting! Tone and attenuation of the aortic component of tone II.

Symptoms depend on the degree of stenosis and hemodynamic disorders. The stage of the defect is determined by the presence of at least one of the following "sufficient" signs of a more severe stage. Stage I: only acoustic signs of a defect. Early maximum amplitude of spindle-shaped noise. Stage P: there are no subjective disorders yet. The maximum of noise is shifted to the middle of the systole. ECG signs are left ventricular hypertrophy. Aortic heart configuration: poststenotic enlargement of the ascending aorta, underlined waist. Stage III; There may be subjective disorders - dizziness, darkening in the eyes, angina pectoris with physical exertion. The pulse is rare, small, with a slow rise. Systolic jittering on the carotid arteries, based on the heart. Low systolic and pulse pressure. Deformation of the carotid sphygmogram in the form of a "cock's crest" with a slow rise and serration of an anacrotic. Stage IV marked disorders of cerebral or coronary circulation at low loads. Mitralization of the defect with the appearance of at least one of the following signs of congestive left ventricular failure: pronounced dyspnea with moderate physical exertion, episodes of cardiac asthma, presystolic gallop rhythm with enhanced pathological IV tone (constantly or occasionally). Some patients have atrial fibrillation. On the ECG, there may be signs of progression of left ventricular hypertrophy, focal changes in the myocardium, blockage of the left leg of the bundle. The lethal outcome usually comes in this stage, often in the previous one. Stage V (terminal) has time to develop only in some patients. Her symptoms are cardiomegaly, right ventricular failure, frequent (repeated within a week) attacks of cardiac asthma, severe angina.

Differential diagnosis. Congenital malformations, including subvalvular and supra-valued stenosis, as well as coarctation of the aorta, subaortic muscular stenosis (see "Cardiomyopathy"), sclerotic lesion of the ascending aorta, relative pulmonary stenosis (physiological or pathological) should be excluded.

Treatment. Drug therapy is ineffective. In the late stages - nitrates, calcium antagonists, ~ 3-adrenoblockers in small doses. Possible surgical treatment (commissurotomy, implantation of an artificial valve).

Insufficiency of the aortic valve. Etiology is usually rheumatic. Rare causes of this defect are subacute septic endocarditis, atherosclerosis of the aorta, and others.

At the forefront are violations of hemodynamics in the arterial link of a large circle. Its function is to smooth the pulsating oscillations of pressure, blood flow and blood flow. The drop in diastopic pressure in the aorta leads to a shortage that contributes to the development of an earlier and severe inconsistency of the overloaded and hypertrophied left ventricle; To myogenic dipatia joins myogenic. Relatively early developed stagnant left ventricular failure, "mitralization" of the defect. In this case, the fate of patients develops relative mitral insufficiency.

Symptoms, course. A characteristic feature is the specific high-frequency blowing diastolic noise in the Botkin-Erba zone, the II tone is weakened or absent. Stage 1: only diastolic noise. In the following stages, the signs of a more severe degree of hemodynamic disorder are listed below. Stage I: there are no subjective disorders. Diastolic pressure is below 55 Hg. Art. , With systolic pressure, 115 mm Hg pain. Art. Sometimes - mild peripheral symptoms (see below). Stage III: Subjective disorders are absent or moderately expressed (palpitation, mild angina, dizziness, sensation of pulsation in the head, in other areas). The diastolic pressure is below 40 mm Hg. from. , Systolic pressure is usually 140 - 1 50 mm Hg. Art. and higher. Expressed peripheral signs of aortic insufficiency (at least one of them): "dance" of carotid; Pulsation of the abdominal aorta; Pseudocapillary pulse, pulse frequent, fast, high; Double noise Durozie over the femoral artery. The reinforced domed apical impulse is shifted to the left and down. Usually there is a "accompanying" systolic murmur of relative aortic stenosis X-ray-aortic configuration, the heart is enlarged ECG signs of left ventricular hypertrophy are possible Stage 1M, severe angina, left ventricular failure with dyspnea at moderate loads There is atrial fibrillation and other cardiac arrhythmias Rhythm Stage V Severe angina pectoris Severe congestive left ventricular failure with frequent (repeated for a month) attacks of cardiac asthma Many patients have dyspnea with insignificant exertion, right ventricular insufficiency develops only as an exception.

Treatment of heart failure requires the use of diuretics and cardiac glycosides. The use of cardiac glycosides may be accompanied by a diastolic lengthening that is disadvantageous with this defect (the indications for their use are specified depending on the individual response to trial treatment with small doses). Vasodilators are also used (see "Heart failure"). Promises the preferences of phenygidine - not a rhythm-prone calcium antagonist. Antianginal drugs (nitro drugs, molsidomin) and vasodilators are used when necessary. Possible surgical treatment (implantation of an artificial valve).

Tricuspidal defect is usually combined with mitral malformation.

The diagnosis is based on the identification of specific noises of insufficiency or (and) stenosis. These noises differ localization at the left edge of the sternum at the level of the fifth to sixth interreberium and, most importantly, their reinforcement on inspiration. With a combined malignancy, the precisystolic murmur of tricuspid stenosis begins, reaches a maximum and ends earlier than the mitral presystolic murmur found in the same patient. Its spindly configuration is clearly revealed. The tricuspid click follows after the mitral, intensifies on inspiration and also gravitates toward the sternum. For the diagnosis of a hemodynamically significant tricuspidal defect, the presence of signs of congestive right ventricular failure is necessary, for a significant tricuspid insufficiency - pulsations of the cervical veins and liver. The severity of pulsation corresponds to the degree of tricuspid insufficiency. In patients with severe tricuspid stenosis with atrial fibrillation, pulsation of cervical veins and the liver is not determined.

Mitral-aortic defect. A severe mitral stenosis with poor left ventricular filling can alleviate the symptoms of aortic stenosis, which no longer has a significant obstacle to a reduced outflow to the aorta. At the same time, in some patients with pronounced aortic and mitral stenosis, the only acoustic sign of the latter is the intense I tone at the apex and its lag; Sometimes this feature is absent.

Mitral-tricuspidal defect. Organic tricuspidal defect accompanies the mitral in about 15% of cases; The relative insufficiency of the tricuspid valve is found in most ballrooms in the later stages of mitral malformation. It is impossible to determine the significance of tricuspidal defect in the development of right ventricular failure, since all the relevant clinical signs can be caused by one mitral malformation. This does not apply to the pulsation of the cervical veins and the liver, which is a specific symptom of tricuspid insufficiency.