Insufficient aortic valve
Aortic valve failure is the pathological movement of the aortic valve structures, which results in the development of marked regurgitation of the blood flow into the left ventricular cavity from the aortic lumen during diastole. Insufficiency of the aortic valve, as an isolated acquired cardiac defect develops quite rarely and is no more than 14% in the overall structure of the incidence of all vices. Significantly more frequent in patients develops a combined damage to the valvular apparatus of the heart in the form of insufficiency and stenosis of the aortic aorta, with the male half of humanity accounting for more than 75% of such cases.
Insufficiency of the aortic valve in children as an isolated organic lesion of the heart occurs in no more than 3% of cases and is verified only at the stage of development of severe cardiohemodynamics disorders.
Causes of aortic valve failure
Until recently, the only etiopathogenetic mechanism for the development of aortic valve insufficiency of varying severity was syphilitic or rheumatic heart disease, and for each of these specific pathologies, the difference in pathomorphological manifestations is characteristic (rheumatism mostly affects the valve flaps in the form of deformity, fracture and even rupture, and with syphilis - valve ring, which sharply expands).
In connection with the successful use of preventive treatment of these nosologies, at present the insufficiency of the aortic valve of rheumatic and syphilitic genesis is extremely rare, and the congenital pathologies of connective tissue with the primary lesion of the ascending aorta are the most important in the etiology of the development of this defect. With the Marfan syndrome , idiopathic necrosis of the mediators of the ascending aorta and Takayasu syndrome , the so-called chronic variant of the aortic valve failure progresses.
Acute expressed regurgitation on the valves of the aortic valve is rare and develops against the background of infective endocarditis , acute aortic dissection, rupture of the aortic aneurysm or aortic valve leaf that has undergone myxomatous changes.
Congenital insufficiency of the aortic valve in an isolated variant is practically not found and is diagnosed exclusively in combination with other cardiac defects.
Symptoms of aortic valve insufficiency
Moderate insufficiency of the aortic valve is characterized by a slowly progressive course and a long asymptomatic period during which the patient has absolutely no complaints of a change in his health, while the valvular heart apparatus is already undergoing changes. The most common complaint of patients, long suffering from aortic valve insufficiency, is the appearance of an unpleasant sensation in the area of the heart, which has a clear connection with its contraction. A characteristic feature is an increased sense of heartbeat when the body is in a horizontal position on the left side, and after pronounced physical activity.
During the unfolded clinical symptom complex, symptoms of cardiac failure appear in the foreground in the form of increasing respiratory disorders, swelling of the extremities and severe weakness.
A specific clinical criterion of insufficiency of the aortic valve of a syphilitic nature is the appearance in the patient of a pain syndrome of the type of "stenocardic attacks" at night, which is explained by an increase in left ventricular myocardial tension in conditions of physiological bradycardia .
Some patients experience a sharp dizziness , until a short-term loss of consciousness of an orthostatic nature (their appearance is associated with a sharp change in the position of the body in space). This symptom is a consequence of the acute development of ischemic damage to the structures of the brain due to the fall of the intraluminal pressure gradient in the aorta during diastole.
The course of aortic valve insufficiency of rheumatic genesis has some features, consisting in the long-term formation of hemodynamic disorders (at least seven years after acute rheumatism).
In view of the lack of severity of clinical manifestations in this cardiac defect, the data of objective examination of the patient and the results of instrumental examination are of primary importance in the correct verification of the diagnosis. There are absolute visual criteria that allow a correct diagnosis at the stage of unfolded hemodynamic disorders, and include: increased pulsation in the projection of the jugular notch and anterior abdominal wall, which corresponds to the projection of the arch of the aorta and its abdominal region, a pronounced pulsation at the neck at the site of carotid artery localization , a sign of Mueller, consisting of a pronounced pulsation of the tonsils and tongue, a sign of Landolphi, consisting in systolic constriction and diastolic dilatation of the pupils.
With palpation of the pulse, tachycardia is noted, but the pulse becomes not only fast, but also high and short. Severe aortic valve insufficiency is accompanied by changes in the pulse pressure, which is an increase in systolic pressure and a decrease in its diastolic index.
In a situation where the patient has a pronounced progressive regurgitation, when performing palpation of the apical impulse, not only his displacement to the left half of the thorax is noted, but also the appearance of the so-called "cardiac shock". However, the detection of auscultative changes in the form of specific cardiac murmurs is most significant in the implementation of the primary diagnosis of aortic valve insufficiency, as a cardiac defect.
Thus, proto-diastolic noise with this defect is heard in the projection of the third-fourth intercostal space along the left parasternal line and is carried to the apex of the heart. With a small degree of regurgitation, one should perform auscultation of the heart in the patient's position while sitting at the height of the maximum exhalation. In addition, with isolated aortic valve insufficiency, both the first and second heart tone decrease, and an additional third tone is auscultated when the signs of left ventricular failure develop. A specific auscultatory criterion of aortic valve insufficiency is the appearance of a loud clapping systolic tone (Traube tone) over the femoral artery.
Degrees of aortic valve insufficiency
The development of aortic valve insufficiency, like any other cardiac defect, is gradual, regardless of the etiology of the disease. Each of the pathogenetic stages is characterized by some or other cardiogeodynamic changes, which is reflected in the patient's state of health. The division of aortic defect in severity is used by cardiologists, and to a greater extent by cardiosurgeons in daily practice, since for each degree the use of a certain amount of medical measures is indicated. The classification is based on both clinical criteria and indicators of instrumental research methods, and therefore, every patient with a suspicion or a previously established diagnosis of "aortic valve insufficiency" needs to undergo a full range of clinical and instrumental examinations.
According to the worldwide cardiological classification, aortic valve insufficiency is divided into four degrees.
The earliest, 1 degree of aortic valve insufficiency is characterized by asymptomatic flow and complete compensation of hemodynamic disorders. The only criterion that allows to establish the correct diagnosis at this stage of the disease is the detection of a small amount of blood (no more than 15%) regurgitating on the valve flaps, which in the Doppler study of the heart is manifested as a "blue stream" with a length of no more than 5 mm from the valves of the aortic valve. Detection of aortic valve failure grade 1 is not a basis for surgical correction of the defect.
The degree of insufficiency of the aortic valve, or the period of "latent heart failure" is characterized by the appearance of complaints of a non-specific nature that appear only after excessive physical activity. When registering electrocardiography in this category of patients there are signs that allow you to suspect changes in the left ventricle of a hypertrophic nature. The volume of the reverse blood flow in Doppler studies does not exceed 30%, and the length of the "blue blood flow" reaches 10 mm.
3 the degree of aortic valve insufficiency, or the period of unfolded clinical symptoms, is characterized by a marked decrease in performance, the appearance of a typical anginal pain syndrome, changes in blood pressure indicators. In the electrocardiographic study, in addition to signs of hypertrophic changes in the left ventricle, the criteria for ischemic myocardial damage are found. Echocardiographic criteria are the detection of a "blue stream" on the aortic valve with a length of more than 10 mm, which corresponds to a blood volume of up to 50%.
The fourth or terminal degree of aortic valve insufficiency is accompanied by severe hemodynamic disorders in the form of the development of a powerful stream of regurgitation, a volume exceeding 50%. At this stage, marked dilatation of all cavitary structures of the heart and development of relative mitral insufficiency are noted.
Treatment of aortic valve insufficiency
Specialists of the cardiological and cardiosurgical profile all over the world adhere to the position of expediency of the applied medical or surgical treatment. Thus, patients with initial aortic valve failure are not shown to use any kind of treatment, except for compliance with the rules of the regime (slight restriction of physical activity).
The volume of drug therapy is limited to the use of medicines, the action of which is aimed at eliminating manifestations of heart failure, in particular diuretics (Furosemide 40 mg once a day), ACE inhibitors (Enap in a minimum dose of 5 mg once a day), cardiac glycosides Digoxin 0.25 mg once a day).
And yet, the only effective method of treating aortic valve insufficiency, like most cardiac defects, is surgical correction of the defect. Absolute indications for the use of any surgical benefit in case of aortic valve insufficiency is the development of signs of left ventricular failure, severe regurgitation on the aortic valve and expansion of the size of the left ventricular cavity. Acute insufficiency of the aortic valve in any situation is an urgent condition and requires immediate surgical removal.
In a situation where the cause of this condition is the damage to the valves of the valvular heart apparatus themselves, the operational benefit consists in excision of the damaged biological material and its replacement with a biological or mechanical prosthesis. With an aortic sinus aneurysm, plastic is produced with the valve retained. The level of mortality in the late and early postoperative period does not exceed 4%.
? Insufficiency of the aortic valve - which doctor will help ? If there is or suspected development of aortic valve insufficiency, you should immediately seek advice from such doctors as a cardiologist and cardiac surgeon.