Aortic stenosis - degrees, symptoms, treatment, causes, prognosis and prevention. Aortic stenosis: symptoms and treatment Aortic stenosis

The narrowing of the aortic opening near the valve entails disruption of normal blood flow in the region of the left ventricle of the heart. This disease is called aortic valve stenosis, or simply aortic stenosis, and is classified as a disease of the cardiovascular system. Such a heart disease is congenital and acquired - up to 30 years it is considered congenital, and after - acquired, or rheumatic. Aortic stenosis is considered one of the most common cardiac pathologies, and occurs in almost 80% of patients (mainly in men).

Aortic valve stenosis is a condition in which the lumen of the valve narrows and stenosis of the aortic orifice, resulting in impaired blood flow from the left ventricle to the systemic circulation.

This heart disease is sluggish, its consequences can make themselves felt many years after the onset.

Symptoms

Cardiac aortic stenosis can be supravalvular, subvalvular, or valvular, depending on its location.

Symptoms of aortic stenosis differ at different stages of the disease, of which there are only five:

Full compensation. This stage is characterized by a very slight deformation of the vessel, and, as a rule, does not require any surgical correction. However, already at this stage of the disease, you should definitely contact a cardiologist for observation.
Hidden heart failure. It is highly desirable to correct this degree of the disease with the help of surgical intervention. Symptoms of the second stage of stenosis can already be seen on the electrocardiogram and during radiography. The patient begins to suffer from shortness of breath, dizziness and fatigue.
Relative coronary insufficiency. In the third stage of aortic stenosis, the intervention of a surgeon becomes necessary. The patient has fainting, angina pectoris begins, shortness of breath increases much.
Severe heart failure. Shortness of breath occurs even when the patient is at rest. Asthmatic attacks begin at night. Surgical operations in the area of the arterial valve are no longer effective, and are simply contraindicated. In some cases, cardiac surgery may help.
Terminal stage. The final stage of the development of the disease. Pathology progresses, treatment with medications does not give any significant results. Shortness of breath is pronounced, edematous syndrome is added to it. Surgery is not possible.

It is easy to conclude that, having noticed dizziness, shortness of breath (up to asthma attacks), excessive fatigue and a tendency to faint, you should immediately visit a doctor - identifying the disease at an early stage will allow for timely medical or surgical correction.

Unfortunately, aortic stenosis can manifest itself at absolutely any age, and often its symptoms can be seen in young children or even newborns. In the latter case, we are most often talking about heredity.

Although other reasons are possible that give impetus to the development of heart disease:

Bacterial endocarditis or rheumatic fever - children who have had these diseases often develop aortic stenosis.
Improper closing of the heart valve, its congenital pathologies.
Some infectious diseases.
At first, you may not notice any manifestations of stenosis in a child, but as the disease progresses, the following symptoms are found:
The heartbeat becomes irregular, in some cases an arrhythmia begins.
The child gets tired very quickly, with strong emotional or physical stress, he faints.
A feeling of tightness begins in the chest, pains arise.

Increased fatigue in a child is one of the causes of aortic stenosis

To fully answer the question of whether it is scary when aortic stenosis develops in children, it should be noted that in certain cases, aortic stenosis in a child ends in sudden asymptomatic death.

In newborn babies, it is quite difficult to diagnose the disease, but the symptoms of aortic valve stenosis appear brighter as they grow older. Doctors recommend that children suffering from this disease avoid emotional stress and physical overwork. Treatment for aortic stenosis usually involves antibiotics.

The reasons

The main cause of the development of the disease is rheumatism of the aortic valves. Due to rheumatism, the valve flaps are deformed, become denser and gradually coalesce, which entails a reduction in the valve ring.

Also, aortic stenosis can develop for reasons such as kidney dysfunction, lupus, and calcification of the aortic valve. The development of the disease is significantly accelerated by factors such as smoking, frequent high blood pressure and hypercholesterolemia.

Treatment of aortic stenosis in the early stages includes constant medical supervision and regular examinations. To begin with, aortic valve stenosis is diagnosed by conducting all the necessary tests and laboratory tests, then appropriate therapy is prescribed.

Medications for aortic stenosis are diuretics (most often Furosemide), cardiac glycosides, and potassium-containing drugs. In more advanced cases, surgical correction is used: balloon plasty and prosthetics.

Prevention

Of course, in cases where aortic stenosis is a congenital pathology, it is inappropriate to talk about prevention. But the development of the acquired form is quite possible to prevent by preventing and timely curing the diseases that cause it. It is worth knowing that even a common sore throat, not properly cured, can give serious complications to the heart.

You need to carefully monitor the condition of your blood vessels, avoiding cholesterol deposits on their walls - in this way you can significantly extend your life and avoid many health problems, both in adulthood and in old age.

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Aortic stenosis is a pathological condition in which a narrowing of the opening occurs in the valve of the same name. For this reason, there is a violation of the outflow of blood from the left ventricle. It belongs to the category of heart defects.

Features of pathogenesis

From the left ventricle, blood flows through the aorta to the main organ systems. This is a large circle of blood circulation. Its weak link is the aortic valve at the mouth of the vessel. It has 3 flaps and opens, passing a portion of the biological fluid into the vascular system. With a contraction, each time the ventricle pushes it out. Closing, the valve is an obstacle to the reverse reflux of blood. In this place, pathological changes occur.

In the case of stenosis, the soft tissues of the cusps and aorta undergo various changes. These may be scars or adhesions, deposits of calcium salts, atherosclerotic plaques or adhesions. As a result, the following violations are observed:

the lumen of the vessel begins to narrow gradually;
valve walls lose their elasticity;
the opening and closing of the valves is not fully carried out;
blood pressure in the ventricle increases.

Against the background of ongoing changes, there is a lack of blood supply to the main organ systems.

The reasons

Aortic stenosis has a congenital or acquired etiology. In the first case, the occurrence of an anomaly is due to a genetic predisposition or pathological abnormalities in the development of the fetus. Normally, the valve has 3 leaflets. With a congenital form of stenosis, this element consists of 2 or 1 cusps.

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However, most often narrowing of the aorta refers to acquired defects. Causes may include the following health problems:

rheumatoid arthritis;
Paget's disease;
diabetes;
calcification/atherosclerosis of the aorta;
lupus erythematosus;
advanced renal failure;
infectious endocarditis.

Doctors identify a number of factors in the presence of which the risk of pathology increases. These include smoking and hypertension.

Classification

Depending on the location, stenosis of the aortic orifice can be:

subvalvular;
supravalvular;
valve.

To assess the severity of aortic stenosis, the classification implies pressure gradient results. This is the difference in blood pressure before and after the aortic valve. In a healthy person, this indicator is minimal. The greater the constriction, the higher the pressure. For example, with grade I stenosis, the gradient ranges from 10 to 35 mm Hg. Art. IV degree is considered critical. In this case, the pressure gradient is more than 80 mm Hg. Art.

In addition, there are several stages in the development of the pathological process. Each of them has a characteristic clinical picture that helps to establish an accurate diagnosis:

stage of compensation. This period is not accompanied by severe symptoms. The heart fully copes with the assigned load. The defect is detected only by auscultation of the muscle.
subcompensation stage. There are initial symptoms of malaise (fatigue, shortness of breath), which increase after physical exertion. Determined by conducting an ECG.
stage of decompensation. It is characterized by obvious heart failure. Symptoms of angina pectoris remain even in a calm state.
Terminal stage. Due to irreversible pathological disorders, death occurs.

Symptoms

In aortic stenosis, symptoms do not make themselves felt for several decades. At the initial stages, when the lumen of the vessel closes by 50% or more, it manifests itself as weakness after exercise.

As the disease progresses, shortness of breath persists after moderate exertion. Almost always it is accompanied by general fatigue and dizziness. When the lumen of the vessel is closed by 75% or more, the patient develops the main signs of heart failure.

Also, the pathology is manifested by the following symptoms:

pallor of the skin;
loss of consciousness;
pressing pains in the sternum;
swelling of the ankles;
violation of the heart rhythm.

Stenosis can cause sudden death without visible external manifestations.

The course of the disease in children

In newborns and preschool children, the disease is often asymptomatic. As they grow, the clinical picture becomes more pronounced due to an increase in the size of the heart. However, the narrow lumen in the aortic valve remains unchanged.

It is possible to diagnose pathology in the fetus already at the 6th month of pregnancy by means of echocardiography. In rare cases, stenosis appears immediately after the birth of the child. In 30% of cases, the condition suddenly worsens by 5-6 months. Among the main symptoms of a violation in newborns, doctors distinguish the following:

frequent regurgitation;
weight loss;
rapid breathing;
the skin has a bluish tint;
lack of appetite.

Aortic stenosis or stenosis of the aortic orifice is characterized by a narrowing of the outflow tract in the region of the aortic semilunar valve, which makes it difficult for the systolic emptying of the left ventricle and the pressure gradient between its chamber and the aorta sharply increases. The share of aortic stenosis in the structure of other heart defects accounts for 20-25%. Aortic stenosis is 3-4 times more common in men than in women. Isolated aortic stenosis in cardiology is rare - in 1.5-2% of cases; in most cases, this defect is combined with other valvular defects - mitral stenosis, aortic insufficiency, etc.

Classification of aortic stenosis

By origin, there are congenital (3-5.5%) and acquired stenosis of the aortic orifice. Given the localization of the pathological narrowing, aortic stenosis can be subvalvular (25-30%), supravalvular (6-10%) and valvular (about 60%).

The severity of aortic stenosis is determined by the systolic pressure gradient between the aorta and the left ventricle, as well as the area of the valvular orifice. With a slight aortic stenosis of the 1st degree, the opening area is from 1.6 to 1.2 cm² (at a rate of 2.5-3.5 cm²); the systolic pressure gradient is in the range of 10–35 mm Hg. Art. Moderate aortic stenosis of the II degree is spoken of with an area of the valve opening from 1.2 to 0.75 cm² and a pressure gradient of 36-65 mm Hg. Art. Severe grade III aortic stenosis is noted when the area of the valvular orifice is narrowed to less than 0.74 cm² and the pressure gradient increases above 65 mm Hg. Art.

Depending on the degree of hemodynamic disorders, aortic stenosis can proceed according to a compensated or decompensated (critical) clinical variant, in connection with which 5 stages are distinguished.

I stage(full refund). Aortic stenosis can be detected only by auscultation, the degree of narrowing of the aortic orifice is insignificant. Patients need dynamic monitoring by a cardiologist; surgical treatment is not indicated.

II stage(hidden heart failure). Complaints are made of fatigue, shortness of breath with moderate physical exertion, dizziness. Signs of aortic stenosis are determined by ECG and radiography, pressure gradient in the range of 36–65 mm Hg. Art., which serves as an indication for surgical correction of the defect.

III stage(relative coronary insufficiency). Typically increased shortness of breath, the occurrence of angina pectoris, fainting. The systolic pressure gradient exceeds 65 mm Hg. Art. Surgical treatment of aortic stenosis at this stage is possible and necessary.

IV stage(severe heart failure). Worried about shortness of breath at rest, nocturnal attacks of cardiac asthma. Surgical correction of the defect in most cases is already excluded; in some patients, cardiac surgery is potentially possible, but with less effect.

V stage(terminal). Heart failure is steadily progressing, shortness of breath and edematous syndrome are pronounced. Drug treatment can achieve only short-term improvement; surgical correction of aortic stenosis is contraindicated.

Causes of aortic stenosis

Acquired aortic stenosis is most often caused by rheumatic lesions of the valve leaflets. In this case, the valve flaps are deformed, spliced together, become dense and rigid, leading to a narrowing of the valve ring. The causes of acquired aortic stenosis can also be atherosclerosis of the aorta, calcification (calcification) of the aortic valve, infective endocarditis, Paget's disease, systemic lupus erythematosus, rheumatoid arthritis, terminal renal failure.

Congenital aortic stenosis is observed with congenital narrowing of the aortic orifice or developmental anomaly - a bicuspid aortic valve. Congenital aortic valve disease usually presents before the age of 30; acquired - at an older age (usually after 60 years). Accelerate the process of formation of aortic stenosis smoking, hypercholesterolemia, arterial hypertension.

Hemodynamic disturbances in aortic stenosis

With aortic stenosis, gross violations of intracardiac and then general hemodynamics develop. This is due to the difficulty in emptying the cavity of the left ventricle, as a result of which there is a significant increase in the systolic pressure gradient between the left ventricle and the aorta, which can reach from 20 to 100 or more mm Hg. Art.

The functioning of the left ventricle under conditions of increased load is accompanied by its hypertrophy, the degree of which, in turn, depends on the severity of the narrowing of the aortic orifice and the duration of the defect. Compensatory hypertrophy ensures long-term preservation of normal cardiac output, which inhibits the development of cardiac decompensation.

However, in aortic stenosis, a violation of coronary perfusion occurs quite early, associated with an increase in end-diastolic pressure in the left ventricle and compression of the subendocardial vessels by the hypertrophied myocardium. That is why in patients with aortic stenosis, signs of coronary insufficiency appear long before the onset of cardiac decompensation.

As the contractility of the hypertrophied left ventricle decreases, the magnitude of stroke volume and ejection fraction decreases, which is accompanied by myogenic left ventricular dilatation, an increase in end-diastolic pressure, and the development of left ventricular systolic dysfunction. Against this background, the pressure in the left atrium and the pulmonary circulation increases, i.e. arterial pulmonary hypertension develops. In this case, the clinical picture of aortic stenosis may be aggravated by the relative insufficiency of the mitral valve (“mitralization” of the aortic defect). High pressure in the pulmonary artery system naturally leads to compensatory hypertrophy of the right ventricle, and then to total heart failure.

Symptoms of aortic stenosis

At the stage of complete compensation of aortic stenosis, patients do not feel any noticeable discomfort for a long time. The first manifestations are associated with narrowing of the aortic orifice to approximately 50% of its lumen and are characterized by shortness of breath on exertion, fatigue, muscle weakness, and palpitations.

At the stage of coronary insufficiency, dizziness, fainting with a rapid change in body position, angina attacks, paroxysmal (nocturnal) shortness of breath, in severe cases, attacks of cardiac asthma and pulmonary edema join. The combination of angina pectoris with syncopal conditions and especially the addition of cardiac asthma is unfavorable prognostically.

With the development of right ventricular failure, edema and a feeling of heaviness in the right hypochondrium are noted. Sudden cardiac death in aortic stenosis occurs in 5-10% of cases, mainly in the elderly with severe narrowing of the valvular orifice. Complications of aortic stenosis can be infective endocarditis, ischemic disorders of cerebral circulation, arrhythmias, AV blockade, myocardial infarction, gastrointestinal bleeding from the lower digestive tract.

Diagnosis of aortic stenosis

The appearance of a patient with aortic stenosis is characterized by pallor of the skin ("aortic pallor"), due to a tendency to peripheral vasoconstrictor reactions; in the later stages, acrocyanosis may be noted. Peripheral edema is detected in severe aortic stenosis. With percussion, the expansion of the borders of the heart to the left and down is determined; palpation felt the displacement of the apex beat, systolic trembling in the jugular fossa.

Auscultatory signs of aortic stenosis are coarse systolic murmur over the aorta and over the mitral valve, muffled I and II tones on the aorta. These changes are also recorded during phonocardiography. According to the ECG, signs of left ventricular hypertrophy, arrhythmias, and sometimes blockade are determined.

During the period of decompensation, radiographs reveal an expansion of the shadow of the left ventricle in the form of an elongation of the arc of the left contour of the heart, a characteristic aortic configuration of the heart, post-stenotic dilatation of the aorta, and signs of pulmonary hypertension. On echocardiography, thickening of the aortic valve flaps, limitation of the amplitude of movement of the valve leaflets in systole, hypertrophy of the walls of the left ventricle is determined.

In order to measure the pressure gradient between the left ventricle and the aorta, probing of the heart cavities is performed, which makes it possible to indirectly judge the degree of aortic stenosis. Ventriculography is necessary to detect concomitant mitral regurgitation. Aortography and coronary angiography are used for the differential diagnosis of aortic stenosis with an aneurysm of the ascending aorta and coronary artery disease.

Treatment of aortic stenosis

All patients, incl. with asymptomatic, fully compensated aortic stenosis should be closely monitored by a cardiologist. They are recommended to conduct echocardiography every 6-12 months. In order to prevent infective endocarditis, this contingent of patients needs preventive antibiotics before dental (caries treatment, tooth extraction, etc.) and other invasive procedures. Pregnancy management in women with aortic stenosis requires careful monitoring of hemodynamic parameters. The indication for termination of pregnancy is a severe degree of aortic stenosis or an increase in signs of heart failure.

Drug therapy for aortic stenosis is aimed at eliminating arrhythmias, preventing coronary artery disease, normalizing blood pressure, and slowing down the progression of heart failure.

Radical surgical correction of aortic stenosis is indicated at the first clinical manifestations of the defect - the appearance of shortness of breath, anginal pain, syncope. For this purpose, balloon valvuloplasty can be used - endovascular balloon dilatation of aortic stenosis. However, this procedure is often ineffective and is accompanied by a subsequent recurrence of stenosis. With minor changes in the leaflets of the aortic valve (more often in children with congenital defects), open surgical plastic surgery of the aortic valve (valvuloplasty) is used. In pediatric cardiac surgery, the Ross operation is often performed, which involves transplanting a pulmonary valve into the aortic position.

With appropriate indications, they resort to plastic surgery of supravalvular or subvalvular aortic stenosis. The main treatment for aortic stenosis today remains aortic valve replacement, in which the affected valve is completely removed and replaced with a mechanical analogue or a xenogenic bioprosthesis. Patients with a prosthetic valve require lifelong anticoagulation. In recent years, percutaneous aortic valve replacement has been practiced.

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The essence of aortic stenosis

The weak link in the systemic circulation (from the left ventricle, blood enters all organs through the aorta) is the tricuspid aortic valve at the mouth of the vessel. Opening, it passes portions of blood into the vascular system, which the ventricle pushes out during contraction and, closing, does not allow them to move back. It is in this place that characteristic changes in the vascular walls appear.

In pathology, the tissue of the valves and the aorta undergoes various changes. These can be scars, adhesions, adhesions of connective tissue, deposits of calcium salts (hardening), atherosclerotic plaques, congenital malformations of the valve.

Due to these changes:

As a result, insufficient blood supply to all organs and tissues develops.

Aortic stenosis can be:

All three forms can be congenital, acquired - only valvular. And since the valvular form is more common, then, speaking of aortic stenosis, this form of the disease is usually meant.

Pathology very rarely (in 2%) appears as an independent one, most often it is combined with other defects (mitral valve) and diseases of the cardiovascular system (ischemic heart disease).

Causes and risk factors

Characteristic symptoms

For decades, stenosis proceeds without showing any signs. In the early stages (before the lumen of the vessel is closed by more than 50%), the condition may manifest as general weakness after serious physical exertion (sports training).

The disease progresses gradually: shortness of breath appears with moderate and elementary exertion, accompanied by increased fatigue, weakness, dizziness.

Aortic stenosis with a decrease in the lumen of the vessel by more than 75% is accompanied by severe symptoms of heart failure: shortness of breath at rest and complete disability.

Common symptoms of narrowing of the aorta:

shortness of breath (first with severe and moderate exertion, then at rest);
weakness, fatigue;
painful pallor;
dizziness;
sudden loss of consciousness (with a sharp change in body position);
chest pain;
violation of the heart rhythm (usually ventricular extrasystole, a characteristic sign - a feeling of interruptions in work, "falling out" of the heart beat);
ankle swelling.

The appearance of pronounced signs of circulatory disorders (dizziness, loss of consciousness) greatly worsens the prognosis of the disease (life expectancy is not more than 2-3 years).

After narrowing of the vessel lumen by 75%, cardiovascular insufficiency progresses rapidly and becomes more complicated:

Aortic valve stenosis can cause sudden death without any external manifestations and preliminary symptoms.

Treatment methods

It is completely impossible to cure the pathology. A patient with any form of aortic narrowing needs to be observed, examined and follow the recommendations of a cardiologist throughout his life.

Drug therapy is prescribed in the early stages of stenosis:

when the degree of narrowing is small (up to 30%);
not manifested by severe symptoms of circulatory disorders (shortness of breath after moderate physical exertion);
diagnosed by listening to noises over the aorta.

Treatment goals:

At later stages, drug therapy is ineffective, the patient's prognosis can only be improved with the help of surgical methods of treatment (balloon expansion of the aortic lumen, valve replacement).

Drug therapy

The attending physician prescribes a complex of drugs individually, taking into account the degree of stenosis and symptoms of concomitant diseases.

The following medicines are used:

Drug group	Name of the medicinal product	What effect do
cardiac glycosides	Digitoxin, strophanthin	Reduce the heart rate, increase their strength, the heart works more productively
Beta blockers	Coronal	Normalize the heart rhythm, reduce the frequency of ventricular extrasystoles
Diuretics	Indapamide, veroshpiron	Reduce the volume of fluid circulating in the body, reduce pressure, relieve swelling
Antihypertensive drugs	Lisinopril	Have a vasodilating effect, reduce blood pressure
Metabolic agents	Mildronate, preductal	Normalize energy metabolism in myocardial cells

In the early stages, acquired aortic valve stenosis must be protected from possible infectious complications (endocarditis). Patients are recommended a prophylactic course of antibiotics for any invasive procedures (tooth extraction).

Surgery

Methods of surgical treatment of aortic stenosis are indicated at the following stages of the disease:

In the later stages (the lumen of the vessel is closed by more than 75%), surgical intervention is contraindicated in most cases (in 80%) due to the possible development of complications (sudden cardiac death).

Balloon dilatation (expansion)

Aortic valve repair

Aortic valve replacement

Ross prosthetics

Patient for life:

is registered with a cardiologist;
is examined at least twice a year;
after prosthetics - constantly takes anticoagulants.

Prevention

Prevention of acquired stenosis is reduced to the elimination of possible causes and risk factors for the development of pathology.

Necessary:

For patients with cardiovascular pathologies, the optimal balance of potassium, sodium, calcium in the diet is of great importance, so the diet should be discussed with the attending physician.

Forecast

Aortic stenosis has been asymptomatic for decades. The prognosis depends on the degree of narrowing of the lumen of the artery - a decrease in the diameter of the vessel up to 30% does not complicate the patient's life. At this stage, regular examinations and observation by a cardiologist are shown. The disease progresses slowly, so the symptoms of increasing heart failure are not noticeable to others and the patient (14-18% of patients die suddenly, without obvious signs of narrowing).

But in most cases, difficulties arise after the closure of the vessel by more than 50%, the onset of angina attacks (a type of coronary disease) and sudden fainting. Heart failure progresses rapidly, becomes more complicated and greatly reduces the patient's life expectancy (from 2 to 3 years).

Congenital pathology ends with the death of 8-10% of children in the first year of life.

Timely surgical treatment improves the prognosis: more than 85% of those operated on live up to 5 years, more than 10 years - 70%.

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The reasons

Congenital narrowing of the aorta occurs due to an anomaly in the development of the fetus - a bicuspid valve. This malformation usually occurs before the age of 30.

Acquired stenosis usually manifests itself at the age of more than 60 years. The causes of acquired narrowing of the aorta can be:

Classification

There are several signs of classification of aortic stenosis:

Depending on the origin, aortic stenosis is distinguished:

Depending on the location of the narrowing:

Subvalvular (up to 30% of cases).
Valvular stenosis of the aorta (frequency about 60%).
Supravalvular (10%).

Depending on the severity, 3 degrees of the disease are distinguished:

1 - the opening of the vessel at the site of narrowing has an area in the range of 1.2-1.6 cm2. (normal size - 2.5-3.5), and the gradient (that is, the difference) of pressure in the heart (its left ventricle) and vessel (aorta) is 10-35 mm Hg.
2 - the values \u200b\u200bof these indicators are 0.75-1.2 cm.sq. and 35-65 mm Hg. respectively.
3 - area up to 0.75 cm2, gradient over 65 mm Hg.

According to the degree of disorders caused by stenosis of the aorta of the heart, there are 2 ways of the course of the disease:

Compensated.
Decompensated (or critical).

Stages of development and symptoms of aortic stenosis

Depending on the severity of the course and the severity of the symptoms, 5 stages of the development of the disease are distinguished:

The lightest. The narrowing of the vessel is insignificant. There are no symptoms. A stenosis is detected by listening (auscultatively). The observation of a cardiologist without special treatment is shown. The first stage is called full compensation.

It is characterized by the following symptoms:

With this degree, the diagnosis is made on the basis of an ECG and/or radiography. The revealed gradient in the amount of 35-65 mm Hg. is the basis for the operation. This stage is accompanied by latent (implicit) heart failure.

Symptoms of stage 3 aortic stenosis (or relative heart failure):

Frequent fainting.
Strong shortness of breath.
The appearance of angina pectoris (attacks of pain in the heart due to insufficient blood supply to the heart muscle).

With a gradient greater than 65 mm Hg. required surgical treatment.

Heart failure is pronounced. Symptoms appear:

Shortness of breath at rest.
Manifestations of cardiac asthma at night, which is manifested by a dry cough, a feeling of lack of air, an increase in diastolic pressure, cyanosis (cyanosis) of the face.

Attacks are relieved with the use of nitroglycerin, painkillers, hypotensive (lowering pressure), diuretics, bleeding, tourniquets on the veins of the extremities and oxygen therapy. In some cases, surgical correction is possible, but less effective than in stage 1-3 aortic stenosis.

Heart failure progresses. Shortness of breath is permanent, edematous syndrome is expressed. The use of medications relieves symptoms for a short time. Surgery at this stage is contraindicated.

Treatment

Control by a cardiologist - every 6 months, patients should be examined, including at the first stage of stenosis.
Drug treatment - is aimed at normalizing the blood supply to the heart, eliminating arrhythmia, regulating blood pressure, relieving symptoms of heart failure.
Surgical treatment of aortic stenosis (performed in the absence of contraindications):

Endovascular balloon dilatation is a percutaneous intervention, an increase in the opening at the site of narrowing of the aorta using a special balloon, which is inflated after insertion. In many cases, this operation is ineffective, and after a while the stenosis appears again.

Open aortic valve repair - used for minor changes in the valve leaflets, for example, in newborns. Correction of the valve in order to restore its functions.

The Ross operation is used in pediatric cardiac surgery. It involves transplanting a valve from the pulmonary artery to the site of the aortic one.

Aortic valve prosthesis - the valve is completely removed, and an artificial prosthesis is inserted in its place.

With timely surgical treatment and constant monitoring, the risk of death for patients with aortic stenosis is significantly reduced.

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When talking about the narrowing of the aorta, you must always clearly know in which place there is a narrowing. It can be at the mouth of the aorta, in the region of the conus arteriosus sinister, in the region of the trunk of the ascending aorta and in the region of the descending aorta, at the site of the so-called isthmus of the aorta, located between the place of origin of the left subclavian artery and the place where the botallian duct enters the aorta.

Stenosis of the aortic mouth has been known in the literature since 1817, but they were studied in particular detail by K. A. Rauchfus in 1869. Descriptions of aortic coarctation appear already in 1760. Stenosis of the aortic mouth is relatively rare, but Rauchfus observed 10 cases, V. P. Zhukovsky - 7, and Theremin - 42.

According to the literature, the longest life expectancy in aortic closure is 27 weeks, but most patients die much earlier, during the first weeks of life.

Stenosis of the aortic orifice occurs as a result of changes in the valves of the aorta - thickening and their fusion, which leads to a more or less significant narrowing of the valve orifice. Behind the narrowing of the opening, there may be post-stenotic dilatation of the aorta. Sometimes there is a combination of stenosis of the aortic cone with stenosis in the valves. The clinical picture of this form will resemble the picture of acquired aortic stenosis.

A congenital narrowing in the region of the aortic arch, especially at the point of transition of the aortic arch to the descending part immediately behind the place: the origin of the subclavian artery, represents a peculiar form. This form of narrowing of the aorta has been known since 1791 and is known as coarctation or stenosis of the aortic isthmus. This area of the aortic arch is normal in children and has a physiological narrowing that does not give any symptoms. But with a stronger narrowing, the lumen of the aorta can decrease to several millimeters in diameter.

There are two types of narrowing of the isthmus of the aorta: adult and children.

In the first type of stenosis, the narrowing is localized below the isthmus and the left subclavian artery, at the point where the arterial canal enters the aorta or even below it, and the stenosis can be expressed to varying degrees.

In the second (children's) type of stenosis of the isthmus of the aorta, narrowing is observed closer to the isthmus, in an area of 4-5 cm, most often before the attachment of the ductus arteriosus, which usually remains open. This is important because it allows free compensatory blood flow from the pulmonary artery to the descending aorta below the constriction. Depending on the location of the narrowing and the degree of narrowing, the clinical picture will vary greatly.

In children's type of isthmus stenosis, clinical symptoms are detected very early. If the stenosis is sharp, then the child already at birth has cyanosis, dyspnea, and he dies shortly after birth. With a lesser degree of stenosis, no symptoms are observed at first, but later a gray-ash color of the skin, shortness of breath and swelling of the lower extremities are revealed. The heart dilates rapidly and a systolic murmur is heard at the base on the right. When measuring blood pressure, it turns out to be greater in the upper limbs than in the lower ones. The pulse on the femoral artery is weaker and palpable in the presence of an open ductus arteriosus. The difference in the degree of oxygen saturation of the blood of the upper and lower half of the body is also characteristic, since the upper blood comes from the left ventricle, and the lower one from the descending aorta, where the blood is diluted with venous blood coming from the pulmonary artery through the ductus arteriosus.

In the adult type of narrowing, the clinical picture is more polymorphic. There may be no symptoms for a long time. There are known cases of detection of stenosis of the isthmus of the aorta in adults who died from any disease or injury, who during their lifetime did not show any complaints and were able to work.

Those suffering from this defect may appear healthy and strong, but sometimes they complain of headaches, dizziness, palpitations, nosebleeds. Shortness of breath appears easily, manifested in some cases by typical crises, true attacks of suffocation, during which the face and limbs become cyanotic and consciousness is lost. These attacks are especially characteristic for children of the first 2 years of life. On examination, attention is drawn to the coldness of the lower extremities, sometimes cramps in the legs, intermittent claudication. Sometimes there is a visible impulse of the heart in the V intercostal space, somewhat to the left of the nipple line. During percussion, the left border of the heart goes beyond the nipple line, the right border - beyond the right edge of the sternum. Systolic trembling is often felt in the mesocardial region, especially distinct at the level of the third intercostal space on the right. A systolic murmur is always heard over the region of the heart, which intensifies as it approaches the base of the heart, reaching a maximum intensity in the second intercostal space on the right.

Noise with equal force is transmitted to the back in the interscapular space and in the subclavian region. Sometimes noise has long character, amplifies at the time of a systole and weakens at a diastole. This peculiarity of the noise depends on the presence of a ventricular septal defect or on an open ductus ductus arteriosus or highly dilated collaterals. Sometimes there are no noises. The second aortic tone is preserved, sometimes accentuated. The pulse of the radial artery is correct, small, the same on both sides. The pulse of the jugular artery lags behind the pulse of the radial artery by 0.1-0.2 seconds. Arterial blood pressure in the arm is rarely normal, more often it is elevated. Sometimes there is a difference in pressure on the right and left. If the difference exceeds 30-10 mm, then it can be assumed that the stenosis is located above the origin of the left subclavian artery. Characteristic is the difference in blood pressure in the arteries of the upper and lower extremities. In the arteries of the lower extremities, there is a decreased systolic and diastolic pressure. The difference can be 10-30 mm Hg. Art.

With an increased load on the heart, a much higher rise in blood pressure (up to 100 mm) can be observed than normal (20-30 mm).

With narrowing of the isthmus of the aorta, there is a slightly increased oxygen capacity with an increase in the content of O2 in the arterial and a decrease in the venous blood, due to which the arteriovenous difference increases.

Very characteristic of adult-type isthmus stenosis is the powerful development of collaterals due to anastomoses between the branching of a. subclavia and a. iliaca interna. In the region of the anterior lateral surface of the chest at the level of the intercostal spaces, on the back, on the posterior surface of the shoulder, one can notice the development of vessels in the form of cords that form plexuses and networks that supply blood to the chest and abdomen, sometimes pulsating and giving sensations of purring and noise when listening. A. mammaria can be projected up to the epigastrium.

This collateral network is not permanent, it can be either more or less noticeable depending on the state of the cardiovascular system.

Stenosis of the isthmus of the aorta of the adult type differs from the child type in the powerful development of collaterals, since in the child type, due to the better blood supply to the lower half of the body, there are fewer grounds for the formation of collateral circulation.

Sometimes it is possible to notice the difference in the filling of the vessels of the neck and upper extremities, which are well palpable and strongly pulsate, and the vessels of the abdominal cavity and lower extremities, which are barely palpable. This difference depends on the degree of stenosis and on the degree of development of collaterals.

Congenital narrowing of the isthmus of the aorta is often accompanied by insufficiency of the aortic valves, which is the cause of diastolic trembling at the base of the heart.

Electrocardiography is determined by a pronounced levogram and sometimes a perversion of the T wave, indicating a lesion of the heart muscle.

Chest X-ray reveals an expansion of the heart mainly to the left and its strong pulsation. Sometimes there is an increase in both the right ventricle and the atrium. The first left arch is usually small, with moderate protrusion. In the oblique position, a slight protrusion and pulsation of the descending aortic arch is determined. When radiography in the posterior-anterior position, it is often possible to observe the expansion of the left supraclavicular artery. In many cases, it is possible to note the presence of patterns in the region of the posterior parts of the upper and lower ribs in the form of semi-lunar notches facing downwards. They are formed in connection with the increased pressure of pulsating arterial collaterals on the lower edge of the ribs.

The angiocardiographic diagnosis of aortic narrowing is best made from an anterior left oblique view. But intravenous administration of contrast does not always give a clear picture, since the contrast at the site of stenosis is already heavily diluted with blood. In these cases, intra-arterial administration of contrast is acceptable, i.e., its introduction directly into the aortic system near the site of narrowing. At the same time, the degree and place of narrowing of the aorta, interruptions of the aortic arch, the presence of the arteriovenous duct, anomalies of the branches of the aortic arch and the collateral network are more clearly revealed. It is highly desirable to also film the heart after injection of a contrast agent into the esophagus (esophagograms) both during systole and during ventricular diastole to recognize the location of the aortic arch in relation to the esophagus.

In view of the fact that angiography does not in all cases provide an impeccable diagnosis of aortic stenosis, it is suggested to resort to thoracoscopy with examination of the anterior superior mediastinum. On the left side of the anterior axillary line, a thoracoscope is inserted into the fourth intercostal space, a pneumothorax is applied, and the aortic arch, the origin of the subclavian artery, the left branch of the pulmonary artery, and the left atrial appendage are examined. After the intervention, the air is aspirated back.

The prognosis for mild narrowing of the adult aorta is relatively favorable. Approximately 1/4 of all those suffering from this lesion live a long time, there are no severe clinical symptoms, as well as a sharp limitation in working capacity. But about 1/4 of patients develop endocarditis, which leads to limited performance and damage to the myocardium. Occasionally, aortic ruptures are observed. Some patients develop hypertension with all its manifestations and complications (in the form of cerebral hemorrhages). But pronounced forms of narrowing of the aorta of the childish type are not very compatible with life. They contribute to the development of infantilism. Children usually die at an early age.

Surgical intervention is indicated for many forms of aortic stenosis in children aged 6-15 years and provides a significant improvement in both the general condition and the blood supply to the lower half of the body. With the improvement of operational technology, indications for operations are expanding. The operation is not beneficial before the age of 6, because the children still have few collaterals, a very narrow aorta, and the anastomosis is difficult. The lethality at operation is defined approximately in 10-15%.

Surgical intervention in children's type of aortic stenosis is difficult, because with it the area of narrowing of the aorta is larger.

- narrowing of the aortic opening in the valve area, which impedes the outflow of blood from the left ventricle. Aortic stenosis in the stage of decompensation is manifested by dizziness, fainting, fatigue, shortness of breath, angina attacks and suffocation. In the process of diagnosing aortic stenosis, ECG, echocardiography, radiography, ventriculography, aortography, and cardiac catheterization data are taken into account. With aortic stenosis, they resort to balloon valvuloplasty, aortic valve replacement; the possibilities of conservative treatment for this defect are very limited.

General information

Classification of aortic stenosis

Congenital aortic stenosis is observed with congenital narrowing of the aortic orifice or developmental anomalies - a bicuspid aortic valve. Congenital aortic valve disease usually presents before the age of 30; acquired - at an older age (usually after 60 years). Accelerate the process of formation of aortic stenosis smoking, hypercholesterolemia, arterial hypertension.

Hemodynamic disturbances in aortic stenosis

Symptoms of aortic stenosis

Diagnosis of aortic stenosis

Drug therapy for aortic stenosis is aimed at eliminating arrhythmias, preventing coronary artery disease, normalizing blood pressure, and slowing down the progression of heart failure.

Forecast and prevention of aortic stenosis

Aortic stenosis can be asymptomatic for many years. The appearance of clinical symptoms significantly increases the risk of complications and mortality.

The main, prognostically significant symptoms are angina pectoris, fainting, left ventricular failure - in this case, the average life expectancy does not exceed 2-5 years. With timely surgical treatment of aortic stenosis, the 5-year survival rate is about 85%, the 10-year survival rate is about 70%.

Measures to prevent aortic stenosis are reduced to the prevention of rheumatism, atherosclerosis, infective endocarditis, and other contributing factors. Patients with aortic stenosis are subject to medical examination and observation by a cardiologist and

aortic stenosis- this is a heart disease in which there is a narrowing of the aortic orifice, which creates an obstacle to the expulsion of blood into the aorta when the left ventricle contracts. The most common cause of aortic stenosis is rheumatic endocarditis. Less commonly, protracted septic endocarditis, atherosclerosis, idiopathic calcification (degenerative calcification of the aortic valve cusps of unknown etiology), and congenital narrowing of the aortic orifice lead to its development. With aortic stenosis, the valve leaflets become fused, thickened, and cicatricial narrowing of the aortic orifice.

Peculiarities of hemodynamics in aortic stenosis. A significant violation of hemodynamics is observed with a pronounced narrowing of the aortic orifice, when its cross section decreases to 1.0-0.5 cm 2 (normal - 3 cm 2).

With aortic stenosis, there are:

Obstruction of blood flow from the left ventricle to the aorta;

Systolic overload of the left ventricle, an increase in systolic pressure and a pressure gradient between the left ventricle and the aorta, which can be 50-100 mm Hg. and more (normally it is only a few millimeters of mercury);

An increase in diastolic filling of the left ventricle and an increase in pressure in it, followed by significant isolated hypertrophy, which is the main compensatory mechanism for aortic valve stenosis;

Decreased stroke volume of the left ventricle;

In the later stages of the disease - a slowdown in blood flow and an increase in pressure in the pulmonary circulation.

Conduct a survey of the patient, find out the complaints.

Patients with stenosis of the aortic mouth do not complain for a long time (the stage of compensation of the cardiovascular system), later they develop pain in the heart area similar to angina pectoris, due to a decrease in blood supply to the hypertrophied muscle of the left ventricle due to insufficient ejection of blood into the arterial system, dizziness, fainting associated with deterioration of cerebral circulation, shortness of breath during exercise.

Conduct a general examination of the patient.

The general condition of patients with aortic stenosis is satisfactory in the absence of signs of circulatory failure. On examination, attention is drawn to the pallor of the skin, which occurs due to insufficient blood supply to the arterial system, as well as due to spasm of the skin vessels, which is a reaction to a small cardiac output.

Examine the area of the heart.

Determine the presence of a cardiac hump, apical impulse, cardiac impulse. When examining the region of the heart, a pronounced pulsation of the chest wall in the region of the apex beat can be detected. The apex beat is clearly visible to the eye, with severe heart disease it is localized in the VI intercostal space outward from the left midclavicular line.

Perform palpation of the heart area.

In patients with aortic stenosis, an abnormal apex beat is palpable (resistant, strong, diffuse, high, outwardly displaced, localized in the 5th, less often in the 6th intercostal space). The symptom of "cat's purr" (systolic trembling) is determined in the II intercostal space at the right edge of the sternum (2 auscultation point). Systolic trembling is more easily detected when holding the breath on exhalation, when the patient is tilted forward, tk. under these conditions, blood flow through the aorta increases. The appearance of the symptom of "cat's purr" in aortic stenosis is due to the eddies of blood as it passes through the narrowed aortic orifice. The intensity of systolic trembling depends on the degree of narrowing of the aortic orifice and the functional state of the myocardium.

Do a heart percussion.

Determine the boundaries of relative and absolute dullness of the heart, the configuration of the heart, the width of the vascular bundle. In patients with stenosis of the aortic mouth, there is an outward displacement of the left border of relative cardiac dullness, aortic configuration of the heart, and an increase in the size of the heart diameter due to the left component.

Perform auscultation of the heart.

At the listening points, determine the number of heart sounds, additional tones, evaluate the volume of each tone. In patients with aortic stenosis, pathological symptoms are detected during auscultation of the heart at the point of auscultation of the mitral valve (above the apex of the heart), at the point of auscultation of the aortic valve (in the II intercostal space at the right edge of the sternum).

Above the aorta (2 auscultation point):

- weakening of the II tone or its absence, due to stiffness of sclerosed, calcified aortic valves, as well as a decrease in pressure in the aorta, which leads to a small excursion and insufficient tension of the valves;

Systolic noise - loud, long, rough, low tone, having a characteristic timbre, defined as scraping, cutting, sawing, vibrating; appears shortly after tone I, increases in intensity and reaches a peak by the middle of the expulsion phase, after which it gradually decreases and disappears before the appearance of tone II;

the maximum noise is usually determined in the II intercostal space to the right of the sternum, it is carried out along the blood flow to the large arterial vessels and is well heard on the carotid, subclavian arteries, as well as in the interscapular space. Systolic murmur in aortic stenosis is better heard on exhalation when the torso is tilted forward. The murmur is caused by obstructed passage of blood through the narrowed aortic orifice during systole.

Above the apex (1 auscultation point):

- weakening of the I tone due to lengthening of the systole of the left ventricle, its slow contraction;

An ejection tone (early systolic click) is heard in some patients in the IV-V intercostal space along the left edge of the sternum, associated with the opening of sclerosed aortic valves.

Pulse. In patients with aortic stenosis, the pulse is small and slow, which is a consequence of low cardiac output, prolonged left ventricular systole, and slow blood flow to the aorta. Determined bradycardia is a compensatory reaction (lengthening of diastole prevents myocardial exhaustion, an increase in the duration of systole contributes to a more complete emptying of the left ventricle and blood flow to the aorta). Thus, with aortic stenosis, pulsus ranis, parvus, tardus are noted.

Arterial pressure. Systolic blood pressure is low, diastolic blood pressure is normal or high, pulse pressure is low.

Identify ECG signs of aortic stenosis.

ECG in patients with aortic stenosis reveals signs of left ventricular hypertrophy and blockade of the left branch of the His bundle.

Signs of left ventricular hypertrophy:

- deviation of the electrical axis of the heart to the left or its horizontal location;

R wave height increase in Vs-6 (R in V 5-6 > R in V 4);

An increase in the depth of the S waves in leads V 1-2;

Expansion of the QRS complex for more than 0.1 sec. in V 5-6;

Decreased or inverted T waves in leads V 5-6 ,

- shift of the ST segment below the isoline in leads V 5-6. A clear relationship is determined between the pressure in the left ventricle, the magnitude of the pressure gradient in the left ventricle and aorta, and the severity of ECG signs of left ventricular hypertrophy.

Signs of blockade of the left leg of the bundle of His.

- the QRS complex is expanded (more than 0.11 sec.);

The QRS complex is represented by a wide and serrated R wave in leads V 5-6 , I, aVL;

The QRS complex is represented by a wide and serrated S wave in leads V 1-2 , III, aVF and looks like rS;

The ST segment and the T wave are directed away from the main wave of the ventricular complex; in leads V 5-6, I, aVL the ST segment is below the isoline, and the T wave is negative; in leads V 1-2 , III, aVF the ST segment is above the isoline, the T wave is positive.

Identify FCG signs of aortic stenosis.

FCG in patients with aortic stenosis reveals changes above the apex of the heart and above the aorta.

Above the aorta:

- decrease in the amplitude of the II tone;

Systolic murmur - increasing-decreasing (rhomboid or spindle-shaped), prolonged, begins shortly after the first tone and ends before the beginning of the second tone, is recorded on all frequency channels (preferably on a low-frequency one).

Above the apex of the heart:

- decrease in the amplitude of oscillations of the first tone;

Ejection tone (detected in half of patients with aortic stenosis, more common with congenital valve damage). The ejection tone (or "systolic click") is a few short fluctuations recorded after 0.04-0.06 seconds. after I tone; determined on the high frequency channel. Its occurrence is associated with the opening of sclerosed aortic valves.

Look for radiological signs of aortic stenosis.

Pathological symptoms are detected by X-ray examination of the heart in direct and left oblique projections.

Direct projection:

- lengthening and bulging of the 4th arc of the left heart circuit due to an increase in the left ventricle;

Aortic configuration of the heart;

Bulging of the upper arches of the right and left contours of the heart due to post-stenotic expansion of the aorta caused by strong vortex blood flows;

Low level of the right atriovasal angle.

In the left oblique projection - posterior bulging of the left ventricle.

Identify signs of aortic stenosis according to echocardiography.

With echocardiography are determined;

Decrease in the degree of opening of the aortic valve cusps during systole;

Thickening of the valve leaflets;

Signs of left ventricular hypertrophy and its dilatation (in the late stages of the development of the defect).