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ACQUIRED HEART VALVULAR DISEASE.
The purpose of the lecture: Introduction of students with acquired heart
disease, the causes of development, clinical features, course of complicated forms,
differential diagnosis, optimal treatment, postoperative care, rehabilitation patients.
Educational goals lectures: Suggestion to students the need for timely
development of appropriate operations to severe complications, and in their
development - familiarity with the most informative and modern methods of
diagnosis and surgical treatment of patients, familiarity with possible
complications and the operation is operating period, they, prevention. The
development of clinical thinking students. The development of the modern view of
the problem from the perspective of the issue of world medicine and general
practice.
Tasks lecture:
1. Give an idea of acquired heart defects.
2. Explain the causes and mechanisms of complications.
3. Give clinical characteristics and options of the disease.
4. Make a differential diagnosis with other diseases.
5. To acquaint students with modern and most informative methods of
examination of patients
6. Showcase their surgical practice: patients, slides, koronagrografii.
7. All material is to prepare and present a lecture to students, to the extent
necessary for quality training of general practitioners.
Plan of the lecture.
1. Urgency of the problem - 5 minutes
2. Etiopathogenesis of acquired heart diseases.
3. Clinical presentation - 10 minutes
a) Etiopathogenesis;
b) Clinical features and diagnosis.
c) Differential diagnosis.
d) Treatment.
4. Diagnostics. - 10 min
5. Differential diagnosis. - 10 min
6. Treatment - 15 minutes
7. HEALTH CARE - 10 minutes
Acquired heart valvular disease
The most common cause of valvular heart disease and the development of a
defect rheumatism, followed by infective endocarditis, coronary heart disease,
which determines postinfarction defects (ventricular septal defect, mitral
regurgitation, aortic heart block), chest injuries. Rare cause is atherosclerosis,
which can lead to a calcified aortic valve stenosis in the elderly.
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Due to connective tissue rheumatic mitral, aortic, tricuspid valve thicken,
grow together, resulting in stenosis or because thinning, distortion, corroded edges
and deposition of calcium salts occurs valvular insufficiency. Distinguish valve
stenosis and insufficiency, and when there is a fusion of the valves and their failure
at the same time, talk about the combined vice. In the latter case, it may be the
prevalence of stenosis or insufficiency. The pulmonary valve is rarely affected
rheumatic process.
Before we begin the presentation of material on acquired heart diseases, it
should be noted that the outcome of any heart disease is chronic heart failure due to
impaired pumping function of one or both ventricles. Proposed a number of
classifications of heart failure, including defects in the heart valves. For single
approach surgeons all over the world adopted known classification of the New
York Heart Association (NYHA), according to which are 4 functional class (FC).
It is based on the signs of heart failure, determined at rest and exercise.
FC 1 - ordinary physical activity does not cause noticeable fatigue,
palpitations, shortness of breath, pain, ie exercise carried as before the illness.
FC 11 - Heart disease is slight limitation of physical activity, at rest no
complaints. Regular physical activity causes fatigue, shortness of breath,
palpitations or chest pain.
FC 111 - there is a marked limitation of physical activity, while a
considerable physical activity causes fatigue, pain, shortness of breath and
palpitations. At rest, the patients are doing well.
FC 1U - Any physical activity is difficult. Subjective symptoms of heart
failure are even at rest.
In the CIS countries is used as the classification of heart failure (NC)
proposed G.F.Langom, V.H.Vasilenko and N.H.Strazhesko. Distinguish 3 stages
of NK.
Stage I - the initial, latent circulatory failure manifested dyspnea, palpitations
and fatigue during exercise. At rest, the symptoms disappear. Hemodynamics is
not broken.
Stage II - in this stage allocated 2 periods. Period A - NC signs alone
expressed moderately, exercise tolerance decreased, are moderate hemodynamic
instability in large and small circulation. Period B - pronounced signs of heart
failure at rest had severe hemodynamic and more, and in the pulmonary
circulation.
Stage III - the ultimate, dystrophic stage with severe violation tions
hemodynamic, metabolic and irreversible changes in the structure of organs and
tissues.
Practice shows that the key to good results of surgical treatment of patients
with valvular heart disease is early, before a comprehensive picture of chronic
disease, referrals to specialized clinics.
Mitral stenosis
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Mitral stenosis - is the most common rheumatic heart disease and is
characterized by adhesions edge mitral valve. Isolated mitral stenosis occurs in 1/3
of all the Mitral valve. According V.H.Vasilenko 100 000 has 50-80 patients with
mitral stenosis.
At the heart defect are sclerotic processes that involve valve, annulus, chordae
and sosochkoye muscle. Mitral stenosis begins with gluing contiguous edges of the
wings. Formed two commissure, which, extending from the ends of wings to the
center's increasingly narrowing the hole
Normally, the area of the left atrioventricular (AV-) holes of 4-6 cm2. Clinical
symptoms of mitral stenosis begin to appear at reducing mitral orifice area less
than 2 cm2
Narrowed mitral orifice is an obstacle to the expulsion of blood from the left
atrium into the left ventricle, due to overflow with blood in the left atrium is
several times high blood pressure. Develop compensatory hypertrophy and
hyperfunction of the left atrium. However, due to the fact that the left atrium - a
rather weak heart, it soon ceases to cope with the extra load. Increasing the
pressure in it is transmitted to the pulmonary veins, and then to the pulmonary
capillaries, and terminal branches of the pulmonary artery. If the value of the
capillary pressure exceeds the oncotic pressure of the blood, pulmonary edema
develops. Spasm of arterioles of the pulmonary artery from the pulmonary
capillaries prevents excessive pressure and increases the resistance in the
pulmonary artery. This neuro-reflex spasm of the arteries contributes to
preservation of the capillary network of the lungs congested, while not reducing
the pressure in the pulmonary veins and the left atrium. However, prolonged
vascular spasm promotes development of sclerotic changes in the small branches
of the pulmonary artery and there is persistent pulmonary "second barrier".
As a result of increased pressure in the pulmonary artery develops
compensatory hypertrophy of the right ventricle, and then to the right atrium.
Considerable strain on the right ventricle in mitral stenosis leads to incomplete
emptying it during systole, increased diastolic blood pressure and the development
of relative tricuspid valve. Stagnation of blood in the venous part of the systemic
circulation leads to an increase of the liver and the appearance of edema, ie
formation of right heart failure. Due to overdistension wall of the left atrium and
its dilatation, damage rheumatic process pathways of the heart, often disturbed the
normal rhythm of the heart and there is atrial fibrillation. Consequently atrial
become completely ineffective, and there is an even greater expansion of the
cavity, which creates conditions for thrombus formation in the left atrium. Rhythm
disturbances (atrial extrasystoles of up to atrial fibrillation) in some patients
developed thromboembolic complications.
Clinic and diagnostics. With a slight narrowing of the mitral valve normal
hemodynamic support the increased work of the left atrium, and patients may not
present any complaints. With the progression of the narrowing and the pressure in
the pulmonary circulation dyspnea and palpitation on exertion. Patients complain
of cough, dry or with sputum containing streaks of blood, weakness, fatigue, less
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pain in the heart and disruption of the heart. With a sharp increase in pressure in
the pulmonary capillaries develop attacks of cardiac asthma and pulmonary edema.
An objective study draws attention to the characteristic "mitral" blush with a
purple tinge on his pale face, cyanosis of the tip of the nose, lips and fingers. On
palpation of the heart can be determined diastolic tremor in the apex ("cat
purring"). Auscultation I tone strengthened (clapping). At the top of the tone is
heard opening of the mitral valve. I flapping sound, combined with voice and tone
II Opening a heart on top of the character ing three-member melody - "rhythm of
quail." In patients with pulmonary hypertension in the second intercostal space to
the left of the sternum audible accent II tone. The characteristic auscultatory
symptoms in mitral stenosis include diastolic murmur, which may occur at
different periods of diastole. On an electrocardiogram revealed signs of surge atrial
overload and right ventricular hypertrophy, electrical axis of the heart is rejected
right P wave increased and split, which is seen as a sign of overload of the left
atrium. Fonokardiograficheskoe study records I gain tone and diastolic murmur
over the apex of the heart, worse during presistoly in sinus rhythm. X-ray
examination of the heart can be seen in the anteroposterior smoothing waist heart,
bulging III arc left contour of the heart by increasing the left atrium. Pulmonary
hypertension at high magnification reveals the second arc of the left path through
the arc bulging pulmonary artery. The characteristic feature of vice is to expand the
left atrial detectable in the second oblique.
Reliable method of diagnosis is echocardiography. Characteristic
echocardiographic features of vice are: a) a one-way movement of diastolic mitral
valve, b) decreased rate of early diastolic mitral valve closure front, c) reduction of
the total trips motion of the mitral valve, d) decrease in diastolic mitral valves
discrepancies and e) increasing the size of the left atrium . Cardiac catheterization
is indicated for mitral combined to determine the degree of mitral regurgitation,
combined with heart defects, with severe pulmonary hypertension - to determine
its extent.
During mitral stenosis depends on the degree of narrowing of the mitral
orifice, and much worse in the development of complications of atrial fibrillation, a
rough fibrosis and calcification of mitral valve thrombus formation in the left
atrium with episodes of arterial embolism, pulmonary hypertension, relative or
organic tricuspid valve. Death occurs due to progressive heart failure, pulmonary
edema, exhaustion.
The method of treatment of mitral stenosis determined by the severity of
patients' state, the degree of hemodynamic instability.
In one class fuktsionalnye patients do not need surgery. Gentle and seasonal
prevention of recurrent attacks of rheumatic fever can maintain blood circulation in
a state of stable compensation. 11 in functional class indications for surgery are
relative. In 111 and 1U functional class absolute indications for surgery.
The choice of surgical treatment depends on many factors. Closed mitral
commissurotomy is indicated for isolated mitral stenosis without gross changes
valve structures, and with concomitant mitral regurgitation grade 1 or calcification
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of the mitral valve of 1 degree. Reconstructive surgery on the mitral valve is
indicated in patients with combined mitral insufficiency with a predominance in
the absence of calcification of the valve and no gross changes in the valves, chords
and papillary muscles.
In severe changes valve structure, calcification of 2 to 3 degrees and
concomitant mitral regurgitation perform prosthetic valve using mechanical or
biological prostheses
Mitral insufficiency
The main causes of the organic forms of mitral insufficiency are rheumatism
and septic (infectious) endocarditis. In rheumatoid arthritis destroyed tissue mitral
valve and edge defects are formed, causing the leaflets do not close during systole
of the left ventricle. In rheumatism mitral insufficiency in pure form is less
common, it is often combined with mitral stenosis or other valve defects. In septic
endocarditis edge defects have tissue flaps and defects located in the body of the
valves. Often found gap chords. Incomplete closing mitral valve causes
regurgitation (regurgitation) of the ventricle to the atrium during ventricular systole
value determines the severity of regurgitation, mitral insufficiency. The left
ventricle is forced to constantly throw more blood, as part of its systole returns to
the left atrium and again enters the left ventricle. Increased blood flow to the left
ventricle hypertrophy, causing it and the subsequent dilatation. Vice of long offset
powerful left ventricle. Gradually developed a significant increase in the left
atrium and ventricle. The pressure in the left atrium increases and further
retrogradely transmitted to the pulmonary veins, ¬ tion increases pressure in the
pulmonary artery, right ventricular hypertrophy develops.
Clinic and diagnostics. Under blemish compensation patients may carry
significant physical activity and the disease is often detected incidentally during
routine inspection. With a decrease in left ventricular contractility and the pressure
in the pulmonary circulation, patients complain of shortness of breath on exertion
and palpitation. In some patients, a cough, dry or with the office of the mucous
sputum, sometimes mixed with blood. More often than in mitral stenosis patients
complain of pain in the heart. With an increase of stagnation in the pulmonary
circulation may be shortness of breath at rest and cardiac asthma attacks.
Appearance of the patient usually does not change. Sometimes revealed
deformity of the chest - "heart hump." Palpation and determined to face enhanced
apical impulse, shifted to the left and down. Auscultation I tone weakened or
absent, accent II tone of the pulmonary artery is moderately expressed. Often apex
auscultated III tone. The most characteristic symptom of auscultatory mitral
insufficiency is a systolic murmur over the top, which takes place in the left armpit
and along the left sternal border. On ECG - signs of left ventricular hypertrophy
and atrial. Identification of right heart hypertrophy is a sign of pulmonary
hypertension. On phonocardiogram amplitude tone I significantly reduced. Systolic
murmur begins immediately after the tone, and I took all the systole, or most of it.
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X-ray examination in the direct projection observed IV curve of the arc on the
left contour of the heart due to dilatation and hypertrophy of the left ventricle. In
addition, the increase in left atrial causes bulging III arc. Increase in left atrial very
clearly revealed in the first oblique lateral view, where the heart moves in an arc
contrast esophagus large radius (greater than 6 cm). At high magnification of the
left atrium may be a shadow of the latter into the right path of the heart in the form
of additional shade. When X-rays in cases of severe mitral regurgitation can be
observed systolic bulging of the left atrium. Isolated mitral regurgitation on an
echocardiogram is characterized by dilation of the left heart, excessive excursion
interventricular septum diastolic multidirectional movement thickened mitral
leaflets and the notable absence of systolic closure.
When intracardiac study determine the amount of regurgitation from the left
ventricle into the left atrium, the pressure in the cavities of the heart and the
pulmonary artery.
With moderate mitral valve patients for a long time remain disabled. Severe
mitral regurgitation quickly lead to severe heart failure and death in patients
The method of treatment of mitral insufficiency determined by the stage of
development of heart failure.
Aortic heart defects
The cause of aortic heart defects may be rheumatic fever, bacterial
endocarditis, atherosclerosis. In frequency lesions of rheumatic process aortic
valve is the second after the mitral. Disease in men occurs 3-5 times more often
than women. Sash aortic valve calcification are often massive, with the transition
to the calcification of the valve annulus, the aortic wall, the myocardium of the left
ventricle. Distinguish between aortic valve stenosis, aortic valve insufficiency, and
combined lesions, when both have stenosis and insufficiency.
Clinic and diagnosis: Patients complain of the presence of dyspnea, pain
stenokarditicheskogo nature in the heart, palpitations and irregular, dizziness and
fainting. Shortness of breath may carry paroxysmal character (cardiac asthma
attacks) and completed the development of pulmonary edema. When aortic defects
death sometimes comes suddenly on a background of apparent prosperity. On
examination, patients show diffuse pripodymayuschy apex beat of the heart, which
is shifted down and to the left with severe aortic valve insufficiency were increased
pulsation of arteries, clearly visible carotid pulse. When aortic valve systolic blood
pressure is raised, characterized by the decrease in diastolic pressure (often zero)
and therefore a significant increase in pulse pressure. When aortic valve listen and
record fonokardiograficheski diastolic murmur, which immediately follows the
tone and II may occupy the entire diastole. This noise is generally decreasing,
extending along the left sternal border, formed a stream of blood returning from
the aorta into the cavity of the left ventricle during diastole. In the projection of the
aortic valve in aortic stenosis is heard rough systolic murmur, which applies to the
carotid artery.
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Radiographically detected increase in the size of the heart by increasing the
left ventricle, the ascending aorta and arch. Talia heart is well developed heart gets
so-called aortic configuration.
Echocardiography helps determine the degree of expansion of the aorta and
the left ventricle, the prevalence of myocardial hypertrophy or dilatation, evaluate
its contractility, diagnose valve calcification and its spread to adjacent structures of
the heart. Cavities of the heart catheterization and angiocardiography is used to
identify the degree of stenosis or insufficiency and assessment of myocardial
contractility, identify areas of akinesia his left ventricle. When strokes perform
coronary angiography for detection of underlying coronary artery patency. When
aortic defects progressive left ventricular hypertrophy leads to relative coronary
insufficiency, angina, focal scarring infarction and death from acute left ventricular
failure.
Treatment operative. In cases of isolated stenosis surgery is indicated when a
pressure gradient between the left ventricle and the aorta exceeding 30 mm Hg.
Art. With aortic stenosis, if the leaflets changed slightly, it is possible
klapanosohranyayuschaya operation - division jointed wings on commissure. In
aortic insufficiency surgery is indicated when the degree of regurgitation II. When
calcified valves, aortic insufficiency, combined stenosis and insufficiency of aortic
valve is the valve.