Aortal insufficiency - the incomplete smykaniye of shutters of the valve of an aorta during a diastola leading to the return current of blood from an aorta in the left ventricle. Aortal insufficiency is followed by dizziness, faints, thorax pain, short wind, frequent and spasmodic heartbeat. For diagnosis of aortal insufficiency the thorax X-ray analysis, an aortografiya, EhoKG, the ECG, heart MPT and KT, a heart kateterization, etc. is carried out. Treatment of chronic aortal insufficiency is performed in the conservative way (diuretics, APF-inhibitors, blockers of calcic channels, etc.); at a heavy symptomatic current plasticity or prosthetics of the aortal valve is shown.
Aortal insufficiency (insufficiency of the aortal valve) – valvate defect at which during a diastola semi-lunar shutters of the aortal valve completely are not closed owing to what there is a diastolic regurgitation of blood from an aorta back in the left ventricle. Among all heart diseases the isolated aortal insufficiency makes about 4% of cases in cardiology; in 10% of observations insufficiency of the valve of an aorta is combined with other valvate defeats. At the vast majority of patients (55-60%) the combination of insufficiency of the aortal valve and a stenosis of the mouth of an aorta comes to light. Aortal insufficiency 3-5 times more often is observed at males.
Reasons of aortal insufficiency
Aortal insufficiency – polietiologichesky defect which origin can be caused by a number of the congenital or acquired factors.
Congenital aortal insufficiency develops in the presence one - two – or the four-folding valve of an aorta instead of three-leaved. Hereditary diseases of connecting fabric can serve as the reasons of defect of the aortal valve: congenital pathology of a wall of an aorta - an aortoannulyarny ektaziya, Marfan's syndrome, Elersa-Danlos's syndrome, , congenital osteoporosis, Erdgeym's disease, etc. At the same time the incomplete smykaniye or a prolapse of the aortal valve usually takes place.
Act as the main reasons for the acquired organic aortal insufficiency rheumatism (to 80% of all cases), a septic endocarditis, atherosclerosis, syphilis, rheumatoid arthritis, system red a wolf cub, Takayasu's disease, traumatic damages of the valve, etc. Rheumatic defeat leads to a thickening, deformation and wrinkling of shutters of the valve of an aorta therefore there is no their full-fledged smykaniye in the period of a diastola. The rheumatic etiology usually is the cornerstone of a combination of aortal insufficiency to mitralny defect. The infectious endocarditis is followed by deformation, an erosion or perforation of shutters, causing defect of the aortal valve.
Emergence of relative aortal insufficiency is possible owing to expansion of a fibrous ring of the valve or a gleam of an aorta at arterial hypertension, aneurism of a sine of Valsalva, stratified aorta aneurism, an ankiloziruyushchy rheumatoid spondilit (Bekhterev's disease), etc. pathologies. At these states separation (divergence) of shutters of the aortal valve can be also observed during a diastola.
Violations of haemo dynamics at aortal insufficiency
Haemo dynamic frustration at aortal insufficiency are defined by the volume of a diastolic regurgitation of blood by defect of the valve from an aorta back in the left ventricle (LV). At the same time the volume of the blood which is coming back to LZh can reach more than a half from the size of warm emission.
Thus, at aortal insufficiency the left ventricle in the period of a diastola is filled as owing to intake of blood from the left auricle, and as a result of an aortal reflux that is followed by increase in diastolic volume and pressure in LZh cavity. The volume of a regurgitation can reach up to 75% of shock volume, and the final diastolic volume of the left ventricle to increase to 440 ml (at norm from 60 to 130 ml).
Expansion of a cavity of the left ventricle promotes stretching of muscle fibers. For exile of the increased volume of blood force of reduction of ventricles increases that at satisfactory condition of a myocardium leads to increase in systolic emission and compensation of the changed intracardial haemo dynamics. However long work of the left ventricle in the hyperfunction mode steadily is followed by a hypertrophy, and then dystrophy of kardiomiotsit: the short period of tonogenny dilatation of LZh with increase in outflow of blood is succeeded by the period of miogenny dilatation with increase in inflow of blood. In the end result the defect mitralization - the relative insufficiency of the mitralny valve caused by LZh dilatation, dysfunction of papillary muscles and expansion of a fibrous ring of the mitralny valve is formed.
In the conditions of compensation of aortal insufficiency function of the left auricle remains undisturbed. At development of a decompensation there is an increase in diastolic pressure in the left auricle that leads to its hyperfunction, and then - a hypertrophy and dilatation. Stagnation of blood in system of vessels of a small circle of blood circulation is followed by increase in pressure in a pulmonary artery with the subsequent hyperfunction and a hypertrophy of a myocardium of the right ventricle. Development of right ventricular insufficiency at aortal defect is explained by it.
Classification of aortal insufficiency
For assessment of degree of expressiveness of haemo dynamic violations and compensatory opportunities of an organism the clinical classification allocating 5 stages of aortal insufficiency is used:
- I \stage of full compensation. Initial (auskultativny) signs of aortal insufficiency in the absence of subjective complaints.
- II \stage of the latent heart failure. Moderate decrease in tolerance to physical activity is characteristic. According to the ECG signs of a hypertrophy and a volume overload of the left ventricle come to light.
- III \stage of subcompensation of aortal insufficiency. Anginozny pains, the compelled restriction of physical activity are typical. On the ECG and roentgenograms - a hypertrophy of the left ventricle, signs of secondary coronary insufficiency.
- IV \stage of a decompensation of aortal insufficiency. The expressed short wind and attacks of cardiac asthma arise at the slightest tension, increase in a liver is defined.
- V \terminal stage of aortal insufficiency. It is characterized by the progressing total heart failure, deep dystrophic processes in all vitals.
Symptoms of aortal insufficiency
Patients with aortal insufficiency in a stage of compensation do not note subjektivyony symptoms. The latent course of defect can be long – sometimes for several years. The exception is made by sharply developed aortal insufficiency caused by stratified aorta aneurism, an infectious endocarditis and other reasons.
The symptomatology of aortal insufficiency usually demonstrates from feelings of a pulsation in vessels of the head and neck, strengthening of warm pushes that is connected with the high pulse pressure and increase in warm emission. Sinusovy tachycardia, characteristic of aortal insufficiency, is subjectively perceived sick as tachycardia.
At the expressed defect of the valve and large volume of a regurgitation brain symptoms are noted: dizziness, headaches, noise in ears, sight violations, short-term unconscious states (especially at bystry change of horizontal position of a body with vertical).
Further stenocardia, arrhythmia (premature ventricular contraction), short wind, the increased sweating joins. At early stages of aortal insufficiency these feelings disturb, mainly, at loading, and further arise also at rest. Accession of right ventricular insufficiency proves hypostases on noyoga, weight and pains in the right podreberye.
Sharply arisen aortal insufficiency proceeds as the hypostasis of lungs which is combined with arterial hypotonia. It is connected with a sudden volume overload of the left ventricle, increase in final diastolic pressure in LZh and reduction of shock emission. In the absence of the special cardiac help the lethality at this state is extremely high.
Diagnostics of aortal insufficiency
Fizikalny data at aortal insufficiency are characterized by a number of typical signs. At external survey pallor of integuments, at late stages – pays attention. Sometimes external signs of the strengthened pulsation of arteries – "dancing " (the pulsation seen approximately on carotids), Musset's symptom (a rhythmical kivaniye the head in a pulse step), a symptom of Landolfi (a pulsation of pupils), "capillary pulse of Quincke" (a pulsation of vessels of a nail bed), Müller's symptom (a pulsation of a uvula and a soft palate) come to light.
Typically visual definition of a top push and its shift in the VI—VII mezhreberye; the pulsation of an aorta is palpated behind a xiphoidal shoot. Auskultativny signs of aortal insufficiency are characterized by diastolic noise on an aorta, the easing of I and II tones of heart "accompanying" with functional systolic noise on an aorta, vascular phenomena (double tone of Traube, double noise of Dyurozye).
Tool diagnostics of aortal insufficiency is based on results of the ECG, a phonocardiography, radiological researches, EhoKG (), kateterization of heart, MPT, MCKT. The electrocardiography finds signs of a hypertrophy of the left ventricle, at a defect mitralization – data for a hypertrophy of the left auricle. By means of a phonocardiography the changed and pathological warm noise are defined. The echocardiographic research allows to reveal a number of characteristic symptoms of aortal insufficiency - increase in the sizes of the left ventricle, anatomic defect and functional insolvency of the valve of an aorta.
On roentgenograms of a thorax expansion of the left ventricle and shadow of an aorta, heart top shift to the left and down, signs of venous stagnation of blood in lungs is found. At the ascending aortografiya the blood current regurgitation via the aortal valve in the left ventricle is visualized. Sounding of cavities of heart at patients aortal insufficiency is necessary for determination of size of warm emission, final diastolic volume in LZh and the regurgitation volume, and also other necessary parameters.
Treatment of aortal insufficiency
Easy degree of aortal insufficiency with the asymptomatic course of treatment does not demand. Restriction of physical activities, annual survey of the cardiologist with performance of EhoKG is recommended. At asymptomatic moderate aortal insufficiency diuretics, blockers of calcic channels, APF-inhibitors, blockers of receptors of angiotensin are appointed. For the purpose of prevention of an infection when carrying out dental and surgical manipulations antibiotics are appointed.
Expeditious treatment – plasticity/prosthetics of the aortal valve is shown at heavy symptomatic aortal insufficiency. In case of sharp aortal insufficiency owing to stratifying of aneurism or an injury of an aorta prosthetics of the aortal valve and the ascending department of an aorta is made.
Are signs of not operability increase in diastolic volume of LZh up to 300 ml; the fraction of emission of 50%, final diastolic pressure of an order is 40 mm of mercury.
Forecast and prevention of aortal insufficiency
The forecast of aortal insufficiency considerably is defined by an etiology of defect and volume of a regurgitation. At the expressed aortal insufficiency without the decompensation phenomena average life expectancy of patients from the moment of establishment of the diagnosis makes 5-10 years. In a dekompensirovanny stage with the phenomena of coronary and heart failure medicinal therapy is ineffective, and patients perish within 2 years. Timely cardiac operation considerably improves the forecast of aortal insufficiency.
The prevention of development of aortal insufficiency consists in prevention of rheumatic diseases, syphilis, atherosclerosis, their timely detection and full treatment; medical examinations of patients of risk group on development of aortal defect.