HEART DISEASES

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

HEART DISEASES - congenital or acquired morphological changes in the valvular apparatus, partitions, walls of the heart or large vessels that leave it, disrupting the movement of blood inside the heart or in the large and small circles of the circulation. Congenital heart defects are characterized by a variety of anomalies of the development of the heart and vessels and are manifested, as a rule, in childhood. Acquired defects are formed in different age periods due to heart damage in rheumatism and some other diseases.

Congenital heart defects are detected in about 1% of newborns; In children of older age groups and adults, they are found much less frequently. The cause of most congenital heart defects are, apparently, the developmental disorders of the fetus under the influence of pathogenic factors in the first months of pregnancy. Such factors can be viral infections, vitamin deficiency, uncontrolled intake of medications (including some vitamins), fetal hypoxia with intrauterine bleeding, etc. An undoubted danger to the formation of heart disease in a child is the abuse of parents by alcohol and smoking . Hereditary nature of congenital heart disease is less than 10% of cases (they are usually combined with other genetically determined deviations in development, for example, with Down's disease).

Congenital heart defects are classified into groups, depending on the nature of the anomaly of the heart structures and the violation of the movement of blood through the chambers of the heart. Possible isolated anomalies of a structure, such as the aorta or pulmonary trunk, with the preservation of the normal direction of the blood flow (stenosis of the aortic aorta, coarctation of the aorta, stenosis of the pulmonary artery); Heart defects with discharge of blood from left to right, i.e. from the left heart to a small circle of circulation (open arterial, or botallas, duct, defects of the interatrial or interventricular septum, etc.); The most severe combined defects of the blue type with discharge of blood from the right to the left (tetralogy of Fallot, transposition of the aorta and pulmonary trunk, single ventricle, common arterial trunk, etc.) or pale type (atrioventricular communication, general atrium, complete abnormal drainage of pulmonary veins).

Clinical manifestations depend on the type of blemish and severity of hemodynamic disorders. In severe defect, the condition of the child immediately after birth can be critical and immediate surgical care is needed. In most cases, the main symptoms of malformation begin to appear at a later age.

Coarctation of the aorta is one of the frequent congenital heart defects, not accompanied by pathological discharge of blood. At the same time, aortic narrowing up to occlusion is revealed, most often in the isthmus region. The upper parts of the body of such patients are better blood supply than the lower ones, therefore, when viewed, sometimes the characteristic features of the physique may be revealed: a well developed shoulder girdle, thin legs, narrow pelvis. The pulse on the femoral artery from both sides is not determined. One of the most important clinical symptoms is that blood pressure (or only on the right arm) is sometimes increased to 250 mm Hg. St., And on the legs is significantly reduced or not determined. The left ventricle working with overload is hypertrophied, which is reflected in the extension of the heart's borders to the left, strengthening of the apical impulse, changes in the ECG, and is confirmed with the help of echocardiography and X-ray study. When auscultation over the heart and between the shoulder blades, systolic murmur is often detected. Treatment is only surgical; The optimal age for surgery is up to 12 years, since in future hypertension can become irreversible and lead to severe heart failure, CNS disorders.

An open arterial (botall) duct is found both in isolated form and in combination with other anomalies. With an isolated variant, the discharge of blood from the aorta into the pulmonary artery is the greater, the wider the lumen of the abnormal anastomosis. Gradually develops pulmonary hypertension, as it grows, complaints of rapid fatigue, dyspnea, pain in the heart; Marked propensity to frequent inflammatory diseases of the lungs. Diagnosis is suggested in the presence of systolodiastolic "machine" noise in the second intercostal space to the left of the sternum. The border of the heart is widened to the left and up; Strengthened, and sometimes splintered II tone on the pulmonary artery. With the help of electrocardiography, echocardiography and X-ray study, hypertrophy and an increase in the left ventricle of the heart, and subsequently the right one, are revealed. Surgical treatment consists of bandaging or crossing the duct; Sometimes endovascular sealing of the duct under X-ray control is used. With a timely operation, the forecast is favorable.

Atrial septal defect (the most common anomaly of heart development), like the open arterial duct, refers to heart defects with a discharge of blood from left to right, which leads to excessive blood filling of the vessels of the lungs. Occurs in various anatomical variants, can be combined with other anomalies of the heart. The vice is characterized by the presence of a hole in the septum between the right and left atria, through which the blood flows from the cavity of the left atrium into the cavity of the right atrium, creating a load on the right ventricle of the heart. The boundaries of the heart are widened more to the right, the accent and splitting of the 2nd tone on the pulmonary artery is determined. The diagnosis is assumed in the presence of a short, rapid systolic murmur in the second intercostal space to the left of the sternum and on the basis of evidence of right ventricular hypertrophy according to ECG data, and also on the basis of the results of echocardiography. Roentgenologically determine the overflow of the arterial vessels of the lungs. Treatment operative - suturing a defect. The forecast for a timely operation is favorable; Operated children. Their physical development is not inferior to healthy peers.

Defects of the blue type are characterized by the discharge of blood from the right heart to the left; The most common is the tetralogy of Fallot: a large defect of the interventricular septum, narrowing of the pulmonary trunk or outlet of the right ventricle, displacement of the aortic aperture to the right, hypertrophy of the right ventricle. Because of the presence of a defect of the interventricular septum and a complicated outflow of blood to the pulmonary vessels in the right and left parts of the heart, almost the same pressure is established. Part of the venous blood from the right ventricle falls directly into the aorta. As a result, all tissues of the body are not adequately supplied with oxygen. There is a delay in the development of the child immediately after birth, the desire to limit physical activity and to squat; Children are prone to frequent acute respiratory infections. The diagnosis is based on the presence in the child of a characteristic cyanosis of the mucous membranes and skin - the so-called central cyanosis, which is aggravated by physical exertion. With auscultation, a systolic murmur is heard over the area of ​​the heart; X-ray examination reveals hypertrophy of the right ventricle (it is confirmed by ECG data), impoverishment of the pulmonary pattern due to insufficient volume of blood entering the vessels of the lungs. The final diagnosis is established based on the data of a special radiopaque examination of the heart. Surgical treatment can be performed only in conditions of a specialized cardiosurgical hospital.

Acquired heart defects are more often represented by narrowing (stenosis) of the aortic aorta (rarely the pulmonary trunk), atrioventricular orifices or incomplete closure or perforation of valvular valves, which leads to a failure of the valve function and regurgitation of blood through the valve defect. In accordance with the localization and nature of heart defects, they are designated as aortic, mitral, tricuspid stenosis or insufficiency. Often the stenosis of the orifice and the inadequacy of the corresponding valve are combined (combined defect): aortic aortic stenosis and aortic valve failure (combined aortic heart disease) or stenosis of the left atrioventricular orifice and mitral valve insufficiency (combined mitral heart disease), etc. If The lesion of two or more holes or valves simultaneously is detected, they speak of a combined defect (for example, combined mitral-aortic defect). To determine the indications for surgical treatment and the prediction of individual defects, they are classified according to the degree of anatomical changes and hemodynamic disorders. If signs of circulatory insufficiency are absent, vice is considered compensated, and from the moment of their appearance - decompensated.

The most common cause of acquired heart defects is endocarditis - rheumatic or (more rarely) of a different nature. Sometimes atherosclerosis , myocardial infarction , heart trauma, including operative , lead to the development of malformation.

Mitral stenosis, or narrowing of the left atrioventricular aperture, almost always has a rheumatic origin. The vice is formed as a result of deformation of the mitral valve flaps and the formation of fusions between them. In the narrow atrioventricular opening, an obstruction to the flow of blood from the left atrium to the left ventricle occurs, which leads to an increase in blood pressure in the left atrium. Its cavity expands, the walls are hypertrophied. Further increase in blood pressure is transmitted to the vessels of the lungs and the right ventricle, which is also stretched and hypertrophied. The ejection of blood from the left ventricle (stroke volume) is reduced; The need for an increase in the volume of circulation is compensated by tachycardia.

Patients may complain of fatigue, dyspnea and palpitation during exercise. Diagnostic value can have the data of examination of the patient. If the defect is acquired in childhood or adolescence, there is a lag in physical development - the patients are asthenic, lean, short (mitral nazism). The skin is pale, but there is a cyanotic ("mitral") flush on the cheeks (sometimes on the nose, chin), and with decompensated vice also cyanosis of the lips, which creates a characteristic appearance of the patient characteristic for this defect. With pronounced mitral stenosis and right ventricular hypertrophy, concussions of the anterior thoracic wall with contractions of the heart (cardiac shock) and an increasing pulsation in the epigastric region are revealed. Percutally, the heart is widened upward (due to an increase in the left atrium) and to the right (due to an increase in the right atrium).

The first tone of the heart on the top of the heart is strengthened, often has a flapping timbre; The second tone at Botkin's point and especially above the pulmonary trunk is strengthened and often also split, which creates a three-membered quail rhythm - pathognomonic auscultatory symptom of mitral stenosis. A highly specific sign of this defect is also the presystolic, i.e., amplified before the first tone of diastolic noise at the apex of the heart and at the Botkin point (the noise is better heard in the patient's position on the left side). Radiographic examination reveals the so-called mitral configuration of the heart due to an increase in the left atrium and right divisions. On the ECG there are signs of hypertrophy of the left atrium and right ventricle. Echocardiography provides reliable diagnostic information about the presence and extent of mitral stenosis.

In process of decompensation of a vice at patients stagnation grows in a small circle of a circulation, there are a dyspnea , a tachycardia , propensity to tussis (display of a stagnant bronchitis). Sometimes hemoptysis (due to rupture of small pulmonary vessels), hoarseness as a result of compression of the left recurrent laryngeal nerve between the enlarged left atrium and the enlarged pulmonary trunk are noted. With significant mitral stenosis, there are attacks of cardiac asthma; With physical exertion often develops pulmonary edema. Pulmonary hypertension leads to sclerosis of the lung vessels, which additionally increases the load on the right ventricle and contributes to its decompensation, which is manifested by increased venous pressure, increased liver, edema (possible ascites , hydrothorax). Due to the constant overstretch of the right atrium, atrial fibrillation often arises in patients, aggravating heart failure and contributing to the development of other complications, in particular, thrombus formation in the atrial cavities and thromboembolism of the pulmonary arteries, arteries of the great circulation.

Treatment of mitral stenosis is only surgical. Usually, dissection of the fused valve flaps (mitral commissurotomy) is performed.

Mitral valve insufficiency in most cases develops in the outcome of rheumatic endocarditis and is caused by deformation and shortening of valve flaps, as well as shortening of their tendon chords, which prevents complete closing of the valves during ventricular systole; While part of the blood returns from the left ventricle to the left atrium. With myocardial infarction, the development of acute mitral insufficiency is possible due to rupture of papillary muscle. The special form of mitral insufficiency is mitral valve prolapse, i.e. Excessive deflection of its valves into the cavity of the left atrium with their opening at a certain point in the systole. The prolapse of the mitral valve may be due to the weakness of the papillary muscles or the dilatation of the tendon mitral valve chords. Myocarditis, myocardial ischemia, diseases characterized by congenital weakness of connective tissue, etc. Mitral valve insufficiency leads to the expansion and hypertrophy of both the left atrium and the left ventricle, whose workload is increased due to work on the movement of the regurgitated volume of blood. Hemodynamic changes in the vessels of the lungs and in the right heart are similar to those observed with mitral stenosis, but they develop later and have a less pronounced character.

The first to appear are complaints of fatigue and dyspnoea with physical exertion. On examination, an enhanced apical pulse of the heart can be detected. Percussion is determined by the expansion of the heart up (due to the increase in the left atrium) and to the left (due to an increase in the left ventricle). The main auscultative symptom is systolic murmur in the region of the apex of the heart, associated with the regulation of blood through a deformed valve. Noise is carried to the left, in the axillary region. In this case, the first tone on the apex of the heart is weakened or not audible at all; The second tone, like the Rule, is strengthened over the pulmonary trunk (the consequence of pulmonary hypertension).

X-ray reveals an increase in the left atrium, the left ventricle, and in case of decompensation of the blemish, also stagnation of blood in the lungs and an increase in the right ventricle. Changes in the ECG in this defect are characterized by signs of hypertrophy of the left atrium and left ventricle. A special method of echocardiography reveals regurgitation of blood through the left atrioventricular aperture, which confirms the diagnosis. In the case of severe mitral insufficiency, valve prosthesis is performed.

The prolapse of the mitral valve is auscultatory characterized by a click (it is associated with untimely opening of valve flaps) and noise audible in the middle of the systole. The click and noise volume is amplified by physical activity (for example, after several sit-ups). The disease can occur without subjective symptoms; Possible sensations of pain and irregularities in the heart (often in patients with extrasystole). In very rare cases, there is a pattern of severe mitral insufficiency, heart failure develops .

Combined mitral malformation is more common than isolated mitral stenosis or mitral valve insufficiency. The clinical picture and surgical tactics depend on which disorder (stenosis or insufficiency) prevails. Sometimes an accurate assessment of the type of violation is possible only on the basis of heart sensing data.

Stenosis of the aortic estuary in adolescence is mainly a consequence of rheumatic heart disease; In elderly people, it is sometimes due to atherosclerosis. Since the discharge of blood from the left ventricle into the aorta is difficult with this defect, the left ventricular hypertrophy develops. Patients are usually pale. Characteristic complaints of fainting, shortness of breath and attacks of angina pectoris with physical exertion. On examination, an increased apical pulse of the heart is noted, shifted to the left. Pulse with severe aortic stenosis slow and small; Systolic and pulse pressure (the difference between systolic and diastolic) is somewhat reduced. Percutally the border of the heart is widened to the left. Above the aorta, a systolic noise is heard, due to the passage of blood through the narrowed and deformed aortic mouth. Noise is often coarse, carried out by the current of blood on the aorta and the carotid arteries. Radiographically and according to the ECG, hypertrophy of the left ventricle is determined. With the help of echocardiography, it is possible to assess the degree of aortic stenosis. Usually vice for many years remains compensated. Decompensation begins with the dilatation of the cavity of the left ventricle, the fibrous ring and the formation of a relative deficiency of the mitral valve with characteristic shortness of breath and attacks of suffocation.

Aortic insufficiency often develops in the outcome of rheumatic or subacute infective endocarditis; It can also be a consequence of syphilitic lesions of the aorta. Hemodynamically, the defect is manifested by regurgitation of part of the blood from the aorta into the left ventricle during diastole. The more regurgitation , the less the amount of blood is distributed into the peripheral capillaries and the greater the overload with the excess volume of blood, the left ventricle of the heart is tested, which is significantly increased and hypertrophied. With severe regurgitation of blood, diastolic blood pressure decreases sometimes to zero, systolic pressure usually increases somewhat (due to an increase in the shock volume of the blood), as a result, the pulse pressure (up to systolic blood pressure values) increases significantly. The magnitude of certain clinical symptoms of the defect depends on the magnitude of the pulse pressure. Often, a marked increase in pulsation ("dance") of the carotid arteries. Usually it is possible to reveal the so-called capillary pulse . To do this, click on the tip of the patient's nail with such force that about half of the nail bed turns pale; With aortic insufficiency, the border between pink and pale coloration pulsates (Quinke symptom). A high and fast pulse is characteristic. The diagnostic value is listening to vascular noise. If you forcefully press the head of the phonendoscope on the femoral artery, and then gradually reduce the pressure, at a certain moment, a double systolodystolic noise is heard (in healthy individuals, only systolic murmur can be heard). With percussion, a significant expansion of the heart to the left is detected. The most important auscultative sign of aortic insufficiency is a delicate diastolic murmur, audible at the very beginning of diastole, immediately after the second heart tone. Noise is usually best heard at the Botkin point. Radiographically, the heart is enlarged to the left by the left ventricle; The cardiac waist, i.e. the angle between the upper contour of the heart and the shadow of the vascular bundle, is underlined (aortic heart configuration). The ECG shows signs of severe left ventricular hypertrophy. The diagnosis is refined with the help of echocardiography.

Decompensation of this defect, as well as aortic stenosis, usually comes late. However, if heart failure develops , then it is not amenable to drug treatment. Surgical treatment of aortic insufficiency and associated aortic defect consists in prosthetics of the aortic valve.

Tricuspid stenosis - narrowing of the right atrioventricular opening in an isolated form is extremely rare and almost always rheumatic. Because of the obstruction to the flow of blood from the right atrium to the right ventricle, the thin-walled right atrium expands, and its myocardium is hypertrophied, which manifests itself on the ECG, radiographically, and the extension of the heart to the right according to the percussion data. Diastolic murmur is unstable above the base of the xiphoid process of the sternum, which is amplified (or appears) after physical exertion, and the strengthened first tone of the heart. X-ray reveals an increase in the right atrium. In a number of cases, echocardiography helps in diagnosis. Decompensation of the blemish is manifested by the expressed stagnation of blood in the veins of the great circle of blood circulation (swelling of the cervical veins, enlargement of the liver, edema, ascites).

Insufficiency of the tricuspid (tricuspid) valve is characterized by regurgitation of blood during systole from the right ventricle to the right atrium, which leads to their hypertrophy, increased pressure in the hollow veins, stagnation of blood in the veins of the great circulation. Regurgitation manifests itself as characteristic of this defect clinical symptoms - a positive pulse (in particular, systolic filling of the cervical veins) and pulsation of the enlarged liver. In patients, as a rule, cyanosis of the face, lips, hands and feet (acrocyanosis) is expressed. Hypertrophy of the right heart is manifested by expanding its boundaries to the right, enhanced by a heart beat, pulsation in the epigastric region, characteristic changes in the ECG. At the base of the xiphoid process of the sternum, a loud systolic murmur is heard, which is amplified by a delay in breathing at the height of inspiration, and a weakening of the first tone of the heart. Decompensation of the defect, as in tricuspid stenosis, is characterized by a significant increase in venous pressure, swelling of the jugular and peripheral veins, an increase in the liver, the appearance of edema, ascites, and hydrothorax.

Treatment of patients with heart defects in the stage of decompensation is always complex. It includes the organization of the necessary regime of physical activity, drug therapy for heart failure and other complications, diet, exercise therapy.

Surgical treatment is the most radical. The presence of congenital heart disease requires mandatory consultation of a cardiac surgeon and, as a rule, is an indication for surgical treatment. Surgical correction of the most common congenital defects - open arterial duct, coarctation of the aorta, defects of the interatrial and interventricular septa, uncomplicated forms of the tetralogy of Fallot and a number of more rare congenital heart defects, are being used, and operations are increasingly being performed on newborns and children of the first year of life. With many congenital heart defects, reconstructive surgeries restore the natural relationship of the heart structures.

The indications for surgical treatment of acquired heart defects were significantly expanded. Defects with a predominant disruption of the function of the aortic, mitral, tricuspid valves, as well as combined defects require surgical treatment in those cases when conservative treatment is ineffective and the usual physical stress causes fatigue, dyspnea, palpitation, and anginal pain in patients. Reconstructive operations with acquired defects are performed in order to preserve the patient's own valvular valves and restore their function, including by valvuloplasty (lacing the valves, using valves of the heart of animals, etc.). If the valve-saving operation is impossible, the valves are replaced with mechanical or biological prostheses. The main contraindication to surgical treatment is the late stage of decompensation of the blemish with marked impairment of blood circulation, which led to irreversible changes in the functions of various organs and systems of the patient's body.

Most heart operations are performed in the conditions of artificial circulation on the Open Heart. After heart surgery, patients need long-term rehabilitation with a gradual recovery of their physical activity. Deterioration of the condition of the operated patient may be associated with the development of complications caused by surgical intervention; Therefore operated patients should periodically undergo examinations in specialized cardiosurgical centers. In the uncomplicated course of the postoperative period, many patients after 6-12 months after surgery are able to return to work. During this period, the special significance is acquired by mental rehabilitation of patients. It is designed to build a patient's sense of confidence in their abilities. In achieving this result, the unidirectional efforts of all health workers, including nurses, in contact with the patient and his relatives play an important role.

The prognosis depends on the type and severity of the defect. In some types of congenital heart disease (open arterial duct, atrial septal defect, isolated pulmonary artery stenosis), patients often live without surgery until they are 20 years old and longer. However, the diagnosis of congenital heart disease is almost always an indication for surgical treatment. A special danger for patients with congenital heart defects is various infectious diseases. In patients with acquired heart defects, the prognosis depends not only on the severity of the defect, but also on the nature of the course of the underlying disease (repeated rheumatic attacks, relapses of infective endocarditis, etc.) and the effectiveness of measures for its treatment and prevention.