Aortic stenosis(aortic stenosis) is a narrowing of the aorta in the area of the aortic valve, which separates it from the heart. As a result, the normal outflow of blood from the left ventricle is disrupted. The disease develops quite slowly. Often this pathology is often combined with damage to the mitral valve, which is located between the left atrium and the left ventricle.
Aortic stenosis accounts for 25% of all heart defects. For unknown reasons, the disease affects men 3 times more often than women. 2% of people over 65 years of age suffer from this defect. And with age, the percentage of people with aortic stenosis increases.
Causes of the disease
Aortic stenosis can be either congenital or acquired.Congenital pathologies, which were formed even before the birth of the baby, more precisely in the first trimester of pregnancy.
- A connective tissue scar under the aortic valve.
- A fibrous diaphragm (film) with an opening that develops over the valve.
- Abnormal valve development. It consists of 2 doors instead of 3.
- Single valve.
- Narrow aortic ring.
Causes of development of acquired aortic stenosis
Systemic diseases associated with impaired immunity
These diseases lead to the growth of connective tissue at the site of attachment of the aorta to the left ventricle, which narrows the lumen of the aorta and interferes with the removal of blood from the heart. Subsequently, calcium is deposited more quickly on the affected areas, which further narrows the duct and makes the valve leaflets inelastic. Infectious diseases associated with bacteria or viruses
- Osteitis deformans is a bone lesion.
- Infective endocarditis is inflammation of the inner lining of the heart.
Diseases associated with metabolic disorders
- Chronic kidney disease.
Regardless of what causes led to aortic stenosis, the result is always the same - blood flow is disrupted and all organs experience deficiency nutrients. This explains the appearance of symptoms of the disease.
Symptoms and external signs
Normally, the hole is 2.5-3.5 cm 2. At the initial stages, when the narrowing is insignificant, aortic stenosis is asymptomatic (grade I, opening 1.6 - 1.2 cm2). The first signs of the disease appear when the valve ring narrows to 1.2 - 0.75 cm 2 (II degree). During this period, shortness of breath may be bothersome during physical activity. When the lumen reaches 0.5 - 0.74 cm 2 (III degree), serious circulatory disorders occur.To determine the degree of aortic stenosis, doctors use a special indicator - pressure gradient. It characterizes the difference in blood pressure before the aortic valve, in the left ventricle, and after it, in the aorta. When there is no narrowing and blood flows into the aorta without obstruction, the pressure difference is minimal. But the more pronounced the stenosis, the higher the pressure gradient.
I degree: 10 – 35 mmHg. Art.
II degree: 36 – 65 mm Hg. st
III degree: over 65 mmHg. Art.
Well-being with III degree of aortic stenosis:
- pale skin;
- fast fatiguability;
- shortness of breath on exertion;
- pain behind the sternum during physical and mental stress;
- violations heart rate– arrhythmia;
- palpitations;
- cough not associated with respiratory diseases and asthma attacks;
- fainting not associated with exertion and stress;
- liver enlargement;
- swelling of the limbs.
- pallor of the skin associated with spasm of small blood vessels in the skin. This is the result of the fact that the heart does not pump enough blood into the arteries and they reflexively contract;
- pulse is slow (less than 60 beats per minute), rare and poorly filled;
- On the chest, the doctor feels a trembling that occurs due to the fact that blood passes through a narrow opening into the aorta. In this case, the blood flow creates turbulences, which the doctor feels under his hand, like vibrations;
- listening with a phonendoscope (tube) reveals a heart murmur and a weakened sound of the aortic valve cusps closing, which is clearly audible in healthy people;
- moist rales are heard in the lungs;
- when tapping, it is not possible to determine the enlargement of the heart, although the wall of the left ventricle thickens.
Instrumental examination data for aortic stenosis
Electrocardiogram (ECG), may be unchanged or show: - left ventricle enlargement;
- left atrium enlargement;
- heart rhythm disturbances;
- disturbances in the conduction of biocurrents through the heart.
Chest X-ray:
- expansion of the aorta above the site of stenosis;
- calcium deposition at the mouth of the aorta;
- signs of congestion in the lungs - areas of darkening.
- thickening of the aortic valve leaflets;
- reduction of the aortic inlet;
- enlargement of the left ventricle.
- signs of a disturbance in the pressure relationship between the left ventricle and the aorta - the pressure gradient increases;
- During contraction, part of the blood cannot escape into the aorta and remains in the left ventricle.
- changes in pressure ratio;
- reduced size of the aortic valve opening.
- atherosclerosis (blockage) of the coronary arteries;
- coronary heart disease – coronary vessels do not sufficiently supply the heart muscle with blood;
- decrease in the amount of blood ejected by the left ventricle.
Diagnostics
Electrocardiogram ECGA common and accessible study of the heart, based on recording electrical impulses that occur during its operation. They are recorded on paper tape in the form of a broken line. Each tooth tells about the distribution of biocurrents in different parts hearts. With stenosis of the aortic mouth, the following changes are revealed:
- enlargement and overload of the left ventricle;
- left atrium enlargement;
- disturbances in the conductivity of biocurrents in the wall of the left ventricle;
- in severe cases of heart rhythm disturbances.
A test in which a beam of X-rays passes through body tissue and is unevenly absorbed by it. As a result, it is possible to obtain images of organs on X-ray film and determine whether there are changes in them associated with the disease:
- expansion of the aorta over the narrowed area;
- darkening in the lungs - signs of edema;
A harmless and painless heart examination with no contraindications. It is based on the properties of ultrasound, which penetrates tissue, is partially absorbed and scattered there. But most of the ultrasonic waves are reflected and recorded by a special sensor. It converts the ultrasound echo into an image that allows real-time observation of the organ's functioning. In order to study changes in the heart as accurately as possible, it is examined from different angles. This reveals the following changes:
- narrowing of the aortic opening;
- enlargement of the walls of the left ventricle;
- calcium deposits on the aortic valve leaflets;
- valve malfunction.
One of the types of ultrasound that allows you to study the movement of blood in the heart. The sensor, like a radar, detects the movement of large blood cells. This makes it possible to determine the difference in pressure in the left ventricle and the aorta. With aortic stenosis it exceeds 30 mm Hg. Art. Catheterization of the heart cavities
A method for studying the heart from the inside. A thin, flexible tube is inserted into a large blood vessel in the thigh or forearm and easily passes to the heart. The doctor controls the progress of the probe using X-ray equipment, which shows in real time where the catheter is located. It can indirectly measure the pressure in the aorta and left ventricle. The diagnosis is confirmed by the following data:
- pressure in the ventricle increases, and in the aorta, on the contrary, decreases;
- narrowing of the aorta;
- disruption of blood outflow from the left ventricle.
The most accurate method for studying the vessels that supply the heart with blood. The study is carried out simultaneously with cardiac catheterization in people over 35 years of age. At this age, disturbances in the functioning of the heart vessels begin. A contrast agent that absorbs X-rays is injected into the blood through a gap in the probe. Thanks to this property, it is possible to see on an x-ray what is happening in coronary vessels hearts. The study helps to identify:
- reduction of the left ventricular cavity;
- thickening of its walls;
- deformation and impaired mobility of the valve flaps;
- blockage of the arteries of the heart;
- increase in aortic diameter.
Treatment of aortic stenosis
If you have been diagnosed with aortic stenosis, you should avoid active species sports and physical activity even if there are no symptoms of illness. It is also recommended to limit your salt intake. If the doctor believes that there is no need for surgery, then you will have to visit a cardiologist regularly (at least once a year). This will help not to miss the progression of the disease and the development of infective endocarditis.Drug treatment
If signs of illness appear, the doctor will recommend taking cardiac glycosides and diuretics. They cannot expand the lumen of the aorta, but improve blood circulation and heart condition. Unlike other diseases leading to heart failure, with aortic stenosis it is not recommended to take beta-blockers and cardiac glycosides with caution.Dopaminergic medicines: Dopamine, Dobutamine
They improve the functioning of the heart, causing it to contract more actively. As a result, the pressure in the aorta and other arteries increases and blood circulates better throughout the body. These drugs are administered intravenously: 25 mg of dopamine is diluted in 125 ml of glucose solution.
Diuretics: Torasemide (Trifas, Torsid)
Accelerates the removal of water from the body, this helps reduce the load on the heart, it has to pump less blood. Swelling goes away, breathing becomes easier. These remedies are gentle and can be taken daily for a long time. Prescribe 5 mg once a day in the morning.
Vasodilators: Nitroglycerin
Taken to relieve heart pain. It is dissolved under the tongue to speed up the effect. But with aortic stenosis, nitroglycerin and other nitrates can cause complications. Therefore, they are taken only as prescribed by a doctor.
Antibiotics: Cephalexin, Cefadroxil
They are used to prevent infective endocarditis (inflammation of the inner lining of the heart) before visiting the dentist, bronchoscopy and other manipulations. Apply 1 g once an hour before the procedure.
Surgery
Surgery is the most effective method of treating aortic stenosis. It must be performed before left ventricular failure develops, otherwise the risk of complications during the operation greatly increases.At what age is it better to perform surgery for congenital aortic stenosis?
It is necessary to eliminate the cause of the narrowing of the aortic mouth before irreversible changes occur in the heart, and it wears out from overwork. Therefore, if a child was born with grade III stenosis, the operation is performed in the first months. If the stenosis is minor, then it is performed after the end of the growth period, after 18 years.
Types of surgery
For prosthetics use:
- Own valve graft pulmonary artery- Ross operation. Instead, an artificial valve is placed in the pulmonary artery. Autograft is given to children and adolescents. It continues to grow, does not wear out and does not lead to blood clots. However, such an operation is considered quite complex and lasts about 7 hours.
- A human valve taken from a corpse. It takes root relatively well, does not cause blood clots and does not require taking blood thinners - anticoagulants. However, over time it wears out. In 10-15 years, surgery will be needed to replace it. Therefore, such prostheses are installed on older people.
- Valves made from bovine or porcine pericardium. Such valves also wear out, which is why they are implanted in people over 60 years of age. Biological transplants do not increase the risk of blood clots, and people do not need to take blood thinners all the time. This is especially important if you have a stomach ulcer or other diseases of the gastrointestinal tract.
- Valves made of artificial materials are mechanical prostheses. Modern materials practically do not wear out and can last for decades. But they contribute to the formation of blood clots in the heart and require the use of anticoagulants (Warfarin, Syncumar) to prevent the formation of blood clots.
Aortic stenosis in newborns
Aortic stenosis in newborns(aortic stenosis) is a narrowing of the body's largest artery, which drains blood from the left ventricle of the heart and distributes it throughout the body. This heart defect occurs in 4 babies out of 1000, and in boys it is 3-4 times more common than in girls. Stenosis can manifest itself in the first days after birth if the opening of the aortic mouth is less than 0.5 cm. In 30% of cases, the condition worsens sharply by 5-6 months. But for most patients, symptoms of aortic stenosis appear gradually over several decades.
Causes of congenital aortic stenosis
Congenital aortic stenosis occurs in a child in the first 3 months after conception. This can lead to:- hereditary tendency;
- bad habits mothers, bad ecology;
- some genetic diseases of the child: Williams syndrome.
- a membrane above the valve with a narrow hole in the center or side;
- valve development abnormalities (single or bicuspid valve);
- tricuspid valve with fused petals and asymmetrical leaflets;
- narrowed aortic ring;
- a cushion of connective and muscle tissue located under the aortic valve in the left ventricle.
Symptoms and external signs of aortic stenosis in newborns
Well-being70% of children with this congenital heart defect feel normal. The worst state of health is in those children whose aortic opening is less than 0.5 cm - III degree of stenosis. A blockage to blood leaving the left ventricle leads to serious circulatory problems. The organs receive 2-3 times less blood than required and they experience oxygen starvation.
After the closure of the aortic duct between the aorta and the pulmonary artery (within 30 hours after birth), the condition of newborns sharply worsens. Symptoms of severe aortic stenosis in newborns:
- pale skin, sometimes blue discoloration on the wrists and areas around the mouth;
- frequent regurgitation;
- weight loss;
- rapid breathing more than 20 times per minute;
- the child sucks weakly at the breast and has shortness of breath.
Objective symptoms
During the examination, the pediatrician detects the following signs of congenital aortic stenosis:- pale skin;
- tachycardia over 170 beats per minute;
- the pulse on the wrists is almost not palpable due to poor filling of the arteries;
- Using a stethoscope, the doctor listens to the heart murmur;
- if a newborn has developed sepsis, then the noise is practically absent due to weak heart contractions;
- peculiarity of the disease - noise is heard in the vessels of the neck;
- The doctor feels a trembling of the chest under the palm of his hand. This is the result of turbulent flows and eddies in the blood flow in the aorta;
- The smaller the opening of the aortic valve, the lower the blood pressure. It may be different on the right and left hand;
- characteristic feature illness - symptoms increase over time.
Data from instrumental examination of aortic stenosis in newborns
Electrocardiography for severe stenosis- left ventricular overload;
- failure in the transmission of biocurrents to the heart;
- disturbances in the rhythm of ventricular contraction.
- signs of congestion in the lungs with severe stenosis - expanded lungs blood vessels;
- the heart is slightly enlarged in the area of the ventricles, and narrowed in the middle - the waist of the heart is pronounced.
- a mass (membrane or cushion) above or below the aortic valve;
- narrowed opening of the aortic valve;
- disturbances in the operation of the valve: it consists of 1 or 2 leaflets, they bend into the cavity of the left ventricle when closing;
- thickening of the muscular wall of the left ventricle due to the proliferation of muscle or connective tissue;
- decreasing the size of the internal space during contraction and relaxation.
Dopplerography
- allows you to assess the severity of stenosis - the size of the aortic inlet;
- helps to calculate the pressure gradient - features of the pressure difference in the left ventricle and in the aorta.
These studies are carried out quite rarely if there is a suspicion that several defects have developed in the heart at once. At the same time, balloon valvuloplasty can be performed to expand the lumen of the aortic valve.
As a result instrumental research The doctor may identify all of the listed signs of aortic stenosis or only some of them.
Diagnostics
Listening to the heart - auscultationListening to the heart with a stethoscope allows you to study the sounds that arise during contractions of the ventricles and the closure of arterial valves, as well as the noise of blood flow through loosely closed valves and a narrowed section of the aorta. With aortic stenosis in newborns, the doctor hears:
- a rough noise in the heart and in the arteries in the neck that occurs when blood passes through a narrowed hole;
- fast and irregular heartbeats.
Method for studying electrical currents in the heart. It is painless and absolutely harmless to the child. Electrical potentials recorded on paper tape in the form of a broken line provide the doctor with information about the functioning of the heart. This study allows you to find out the rhythm of the heart, the load experienced by the atria and ventricles, the conductivity of biocurrents and the general condition of the heart muscle. With stenosis of the aortic mouth in newborns, the following appears:
- signs of left ventricular overload;
- tachycardia (fast heartbeat) in a newborn, more than 170 beats per minute;
- heart rhythm disturbances - arrhythmia;
- Occasionally, signs of thickening of the heart in the left ventricle are noticeable.
Diagnostic method using x-rays. It passes through human tissues and organs and leaves an image on the film. From the images you can judge how the organs are located and the changes that occur in them. A painless and widespread method that allows you to get results quickly. Its disadvantage: the child receives a small dose of radiation and in order for the picture to come out clear, the baby must lie still for several seconds, which is not always possible. Signs of aortic stenosis in newborns:
- enlarged left side of the heart;
- sometimes there are signs of blood stagnation in the lungs, which appear as darkening on the image.
The method is based on the property of ultrasound to be reflected from organs and partially absorbed by them. Various modes: M-, B-, Dopplerography and the placement of the sensor in different positions allow you to study in detail all parts of the heart and its work. The study does not harm the child’s health and does not cause any discomfort. In newborns, aortic stenosis is indicated by: - deformed aortic valve cusps;
- reduced opening of the aortic mouth;
- the appearance of turbulent blood flow in the aorta. Swirls and waves occur when blood passes under pressure through a narrowed area;
- reduction of the cavity of the left ventricle due to the proliferation of its walls;
- changes in the level of blood pressure in the left ventricle and aorta during heart contraction.
Examination of the heart using a thin tube - a catheter. It is injected through the vessels into the cavity of the heart. Using a probe, you can determine the pressure in the chambers of the heart and inject a contrast agent, after which they do x-rays. They allow you to determine the condition of the heart vessels and its structures. For newborn children, the study is carried out under general anesthesia. Because of this, catheterization is rarely performed in newborns. Signs of aortic stenosis:
- narrowing of the aorta;
- an increase in pressure in the left ventricle and a decrease in it in the aorta.
Treatment
Without treatment, mortality from aortic stenosis in the first year of life reaches 8.5%. And 0.4% every next year. Therefore, it is very important to follow the doctor’s recommendations and undergo examination on time.If there is no urgent need for surgery, it can be postponed until age 18, when the growth period has ended. In this case, it will be possible to install an artificial valve that does not wear out and does not require replacement.
Drug treatment
Taking medication does not eliminate the problem, but it can alleviate the symptoms of the disease, improve heart function and eliminate blood congestion in the lungs.
Prostaglandins (PGE)
These substances prevent the open ductus arteriosus from closing. They are administered on the first day to those children whose aortic opening is only a few millimeters. In this case, the connection between the aorta and the pulmonary artery (patent ductus arteriosus) improves blood circulation in the lungs and nutrition of the organs. In order to maintain the arterial duct open before surgery, PGE 1 is administered intravenously using a dropper at a rate of 0.002-0.2 mcg/kg per minute.
Diuretics or diuretics: Furosemide (Lasix)
Prescribed to newborns if there are signs of pulmonary edema and breathing problems. The drugs accelerate the excretion of excess water in the urine. But at the same time, the child’s body also loses electrolytes - the minerals potassium and sodium necessary for life. Therefore, during treatment, blood and urine samples are periodically taken to monitor their chemical composition. Diuretics are prescribed in the following dosage: 0.5-3.0 mg per kilogram of weight. They are administered intravenously, intramuscularly or by mouth.
Cardiac glycosides, adrenergic blockers, aldosterone antagonists and digoxin are extremely rarely prescribed for aortic stenosis in newborns. These drugs reduce the pressure in the blood vessels, and with this defect, the blood pressure in the aorta and other arteries is reduced.
Types of operations for aortic stenosis in newborns
Surgical treatment is the only effective method to restore heart health.The answer to the question: “at what age should surgery be performed?” is decided individually and depends on the degree of narrowing of the aortic mouth. If the hole is less than 0.5 cm and the child’s condition is serious, then the operation is performed in the first days of life. In some cases, a team of cardiologists goes directly to the maternity hospital. But if the child’s well-being allows, then they try to carry out the operation at a more mature age, but in this case it is necessary to visit a cardiologist 1-2 times a year and do an ultrasound of the heart.
Contraindications to the operation are:
- Sepsis is blood poisoning.
- Severe left ventricular failure (underdevelopment or proliferation of connective tissue in its walls).
- Concomitant severe diseases of the lungs, liver and kidneys.
- Balloon valvuloplasty for aortic stenosis in newborns
A small hole is made in a large artery in the thigh or forearm, through which a thin probe (catheter) with a balloon at the end is inserted. It is advanced along the vessel to the narrowed area of the aorta. The entire process takes place under the control of x-ray equipment. When the balloon reaches the desired location, it is sharply inflated to the right size. In this way, it is possible to expand the lumen of the aorta by 2 times.Indications for use
- disturbances in the outflow of blood from the left ventricle;
- ischemic disease associated with impaired blood circulation in the walls of the heart and deterioration of its functioning;
- the difference in pressure between the left ventricle and the aorta is 50 mm Hg. Art.;
- heart failure - the heart does not pump blood through the vessels effectively enough, and the child’s organs lack nutrients and oxygen.
- low-traumatic operation in which there is no need to open chest;
- well tolerated by children;
- minimal percentage of complications;
- blood circulation immediately improves;
- The recovery period takes several days.
- impossible to perform if there are judgments in other parts of the aorta;
- after a few years, the mouth of the aorta may narrow again and a repeat operation will be required;
- not effective enough for subvalvular aortic stenosis;
- As a result of the operation, aortic valve insufficiency may occur and prosthetic replacement will be required;
- not effective if there are defects of other heart valves.
- Aortic valve plastic surgery in newborns
The heart surgeon makes an incision in the middle of the chest and temporarily stops the heart. Through an incision in the left ventricle, the doctor cuts through the fused sections of the valve leaflets that prevent it from opening completely. Advantages
- allows you to keep your own valve. It does not wear out and does not require replacement when the child grows up;
- there is no need to take anticoagulants to prevent blood clots;
- allows the child to lead an active lifestyle in the future.
- in some cases, the valve leaflets may grow back together;
- requires connection to a machine for artificial blood circulation;
- a scar will remain on the child’s chest;
- It will take several months to recover after the operation.
- Aortic valve replacement in newborns
An incision is made in the chest and large vessels are connected to a heart-lung machine. The child's body temperature is reduced by about 10 degrees using a heat exchanger to prevent brain damage as a result of oxygen deprivation. After this, the valve is replaced.Types of prostheses:
- Biological prosthesis of their pig or bovine heart. The advantage is accessibility; you do not need to constantly take anticoagulants. Disadvantage: it wears out within 10-15 years and requires replacement.
- Prosthesis made of artificial materials. The advantage is reliability and long term services. Disadvantage: It causes blood clots and requires constant use of medications to thin the blood. As the body grows, the valve becomes small, and repeated surgery is needed to replace it with a larger implant.
- Transplantation of your own valve from the pulmonary artery (Ross operation). A biological prosthesis is placed in the pulmonary trunk. The advantage is that such a valve in the aorta does not wear out and grows with the child. Disadvantages: the operation is complex and lengthy, and it may be necessary to replace the valve in the pulmonary artery.
- the pressure difference between the left ventricle and the aorta is greater than 50 mm Hg. st;
- the opening of the aortic mouth is less than 0.7 cm;
- aortic aneurysm or narrowing in different parts of it;
- damage to several heart valves;
- narrowing below the aortic valve.
- during the operation, the doctor can eliminate all defects that have developed in the heart;
- the operation is effective for any lesions of the aortic valve;
- avoids aortic valve insufficiency.
- the operation lasts 5-7 hours and requires connection to a heart-lung machine;
- after the operation there is a scar on the chest;
- full recovery takes 3-5 months.
Aortic valve defects rank second in frequency after damage to the mitral valve among all acquired heart defects. In most cases, a combination of aortic stenosis with aortic valve insufficiency is observed, while isolated aortic stenosis is much less common.
The aortic valve is formed by connective tissue and consists of three valves that open when blood moves from the left ventricle to the aorta (one of the largest blood vessels in the body, providing oxygen-rich blood to the entire body). Normally, the area of the aortic valve opening is three to four square centimeters. If any pathological process at the aortic orifice (the place where the aorta exits the left ventricle) affects the valve leaflets, this leads to the development of scar changes in them and the formation of narrowing (stenosis) of the valve opening.
Thus, aortic stenosis is a disease related to defects of the heart and large vessels, resulting from organic damage to the heart, as a result of which a pronounced obstruction is created in the path of blood flow into the aorta, which affects the supply arterial blood vital organs and the entire body.
There are congenital and acquired aortic stenosis. In turn, congenital stenosis can be supravalvular, valvular and subvalvular, and acquired stenosis is almost always localized in the leaflets (valvular stenosis). Below we will look at the main signs and treatment of acquired aortic valve stenosis.
Causes of acquired aortic stenosis
In most cases (about 70 - 80%), aortic stenosis is caused by rheumatism and bacterial endocarditis (more often in young people). In older people, aortic stenosis can be caused by the development of atherosclerotic plaques on the walls of the aorta, as well as the deposition of calcium salts in the valve leaflets affected by atherosclerosis.
Symptoms of aortic stenosis
The basis of the clinical signs is a violation of hemodynamics (blood flow) both inside the heart and throughout the body. The aorta, and, consequently, all internal organs, receives much less blood than a normally functioning heart. This is manifested by symptoms such as frequent dizziness, pale skin, lightheadedness, deep fainting, muscle weakness, pronounced fatigue, and sensations of strong heartbeats.
Due to the fact that the muscle mass of the left ventricle increases to overcome resistance to blood flow (left ventricular hypertrophy occurs), and the coronary (own heart) vessels are not able to supply the heart muscle with oxygen, angina develops. In this case, the patient is bothered by attacks of chest pain, radiating to left hand or into the shoulder blade, occurring during physical activity or at rest.
As the cardiac muscle grows in other chambers of the heart (left atrium, right ventricle), due to its inability to cope with resistance, signs of blood stagnation appear in the vessels of the lungs, liver, muscles, kidneys and other organs. The patient is bothered by shortness of breath when walking or at rest, attacks of “cardiac” asthma with episodes of pulmonary edema (severe shortness of breath at rest and in the lying position with bubbling difficulty breathing), pain in the right hypochondrium, abdominal enlargement due to congestion in abdominal cavity fluids, swelling lower limbs. Rhythm disturbances are much less common than with mitral defects, and, as a rule, ventricular extrasystole is recorded more often.
All of these symptoms manifest themselves differently depending on the stage of the process.
So, in compensation stages the heart copes with the increased load on it, and symptoms do not appear for a certain period of time (for example, for decades, if the defect has developed in at a young age and the degree of narrowing is not very pronounced).
IN subcompensation stages(hidden heart failure) symptoms appear when performing significant physical activity, especially unusual for the patient.
IN stages of decompensation- severe heart failure, severe heart failure and terminal heart failure - the above symptoms bother the patient not only when performing minimal household activities, but also at rest.
IN terminal stage death occurs due to complications and irreversible changes in the cells of the heart and vital organs.
Diagnosis of aortic valve stenosis
Sometimes, in the absence of complaints, aortic stenosis can be diagnosed accidentally during a routine examination of the patient. If there are complaints from the heart, the diagnosis is established in accordance with using the following methods research:
- clinical examination: complaints, medical history and appearance of the patient are assessed, and auscultation (listening) of the chest is performed, during which the doctor detects a rough systolic murmur at the point of projection of the aortic valve - in the second intercostal space to the right of the sternum, moist rales in the lungs due to stagnation of blood in them , if any;
- laboratory research methods: during general analyzes blood and urine, biochemical and immunological blood tests reveal signs inflammatory process, for example, repeated rheumatic attacks or sluggish bacterial endocarditis; signs of liver and kidney dysfunction; signs of lipid metabolism disorders in atherosclerosis - increased cholesterol levels, imbalance of high and low density triglycerides, etc.;
- instrumental methods research: ECG is performed (single or daily monitoring according to indications), phonocardiography (PCG is a research method that allows you to convert the sound signals of heart murmurs into electrical signals, record them on photographic paper and conduct a more complete analysis of sound phenomena in heart defects), chest radiography, echocardiography (Ultrasound of the heart). Ultrasound of the heart is the only non-invasive (without penetration into body tissue) methods that make it possible to clarify the diagnosis. When carrying out this method, the number, structure, thickness and mobility of the leaflets, the degree of narrowing of the valve opening with measurement of its area, the degree of hemodynamic disturbances are assessed - hypertrophy of the left ventricle with an increase in its volume, an increase in pressure in the left ventricle and a decrease in the aorta, a decrease in stroke volume and fraction ejection (the amount of blood ejected into the aorta in one heartbeat).
Depending on the degree of narrowing of the valve ring at the mouth of the aorta, it is customary to distinguish three degrees of aortic stenosis:
Grade 1 – minor stenosis – the area of the valve ring opening is more than 1.6 square meters. cm.
2nd degree – moderate stenosis – area is 0.75 – 1.6 sq. cm.
3 degree – severe stenosis – narrowing area less than 0.75 sq. cm.
In diagnostically unclear cases, as well as before valve surgery, catheterization of the heart chambers with measurement of the pressure difference in the left ventricle and in the aorta may be indicated. This pressure gradient is also the basis for the classification, with a slight stenosis corresponding to a gradient of less than 35 mm Hg, moderate stenosis - 36 - 65 mm Hg, severe stenosis - above 65 mm Hg, that is, the greater the stenosis and obstruction to blood flow, the the pressure in the left ventricle is higher and the pressure in the aorta is lower, which adversely affects the walls of the ventricle and the blood supply to the whole body.
Treatment of aortic stenosis
The choice of the optimal treatment method is determined individually by the attending physician for each individual patient. Medications, aortic valve surgery, and a combination of these are used.
From pharmacological groups The following drugs can be prescribed: diuretics (veroshpiron, indapamide, furosemide), cardiac glycosides (digitoxin, strophanthin), drugs that lower blood pressure (perindopril, lisinopril) and reduce heart rate (concor, coronal). The listed drugs are prescribed strictly according to indications in connection with a possible significant decrease in blood pressure, and the attending physician must be notified of any deterioration in well-being.
Drugs that dilate peripheral vessels and are used in the treatment of pulmonary edema and angina pectoris (nitrates - nitroglycerin, nitrosorbide) are not always used and with extreme caution, since their use in angina pectoris due to aortic stenosis (relative coronary insufficiency) is, firstly, ineffective, and secondly, it is fraught with a sharp decrease in pressure up to the development of collapse with limited blood flow to the organs and tissues of the body.
A radical way to cure aortic valve stenosis is cardiac surgery. The operation is indicated for moderate and severe degrees of stenosis and the presence of hemodynamic disturbances and/or clinical manifestations. For moderate stenosis, valvuloplasty can be used (dissection of adhesions and adhesions in the valve leaflets), and for severe stenosis, especially if it is combined with insufficiency, valve replacement (replacing it with an artificial mechanical or biological prosthesis) is possible.
Aortic valve replacement with a mechanical prosthesis
Lifestyle with aortic stenosis
Compliance with lifestyle recommendations for this defect is not much different from other cardiovascular diseases. The patient must avoid physical activity, limit fluid and salt intake, give up alcohol, smoking, fatty, fried, and cholesterol-rich foods. You also need to constantly and regularly take prescribed medications and visit your doctor to carry out the necessary diagnostic measures.
If pregnancy occurs with aortic stenosis, the doctor’s tactics for maintaining pregnancy depend on clinical stage process. In the stages of compensation and subcompensation, pregnancy can be prolonged, but decompensation of the defect is an indication for termination of pregnancy. This is explained by the fact that during gestation the load on the pregnant woman’s circulatory system increases, and this can lead to a deterioration in hemodynamic parameters and the development of complications on the part of the mother and fetus (threat of premature birth, fetoplacental insufficiency, and others).
Complications of aortic stenosis
Without treatment, this disease strictly goes through all five stages of its development, that is, sooner or later degenerative irreversible changes occur in the heart muscle, lungs, brain, liver, kidneys and other organs, which entails death. According to some authors, more than half of patients who do not receive treatment die in the first two to three years after the onset of severe clinical symptoms. It is also likely that complications will develop, life-threatening humans - fatal cardiac arrhythmias (for example, ventricular fibrillation, complete atrioventricular block, ventricular tachycardia), sudden cardiac death, acute heart failure, systemic thromboembolism (release of blood clots into the vessels of the lungs, heart, brain, intestines, femoral arteries).
Complications can develop not only as a result of long-term aortic stenosis, but also during surgery on the aortic valve, in particular, the development of bacterial inflammation on the valve leaflets as a result of pathogens entering the blood - bacterial endocarditis, the formation of blood clots on the leaflets or in the cavities of the heart with possible their release into the blood vessels, heart rhythm disturbances, the occurrence of repeated stenosis (restenosis) in the late postoperative period as a result of repeated rheumatic attacks. Prevention of such complications is the lifelong use of anticoagulants and antiplatelet agents - drugs that “thin” the blood and prevent increased thrombus formation, for example, chimes, warfarin, clopidogrel, aspirin and many others. In addition, the use of antibiotics in the early surgical period and during therapeutic and diagnostic procedures and minor operations in the patient’s subsequent life, for example, during tooth extraction, research, prevents the development of infectious complications. Bladder with his catheterization, abortions and so on.
Forecast
The prognosis without treatment is unfavorable. After surgical correction of the defect, clinical and hemodynamic parameters improve, and the survival rate of this category of patients reaches about seventy out of a hundred within ten years after surgery, which is a fairly good criterion for successful cardiac surgical treatment of aortic stenosis.
General practitioner Sazykina O.Yu.
Aortic valve stenosis – one of the most common heart diseases, which is more common among men than among the female half of the population. This disease is usually acquired. This pathology is much less common than congenital.
This cardiac disease represents pathological changes heart valve, in which the opening of the heart valve becomes smaller, slowing down the flow of blood. Blood, not flowing actively enough from the left ventricle, over time begins to poorly perform all its basic functions, which negatively affects the condition of the body as a whole. In old age, this occurs due to wear and tear of the heart. In people under 60, it may be due to mitral valve insufficiency.
The heart valve consists of three parts - leaflets. Much less common of the two. The butterfly valve wears out prematurely, resulting in unpleasant consequences, such as the accumulation of calcium salts, scarring and reduced mobility of the valve leaflets. Every tenth person with a bicuspid valve develops cardiac dysfunction.
Degrees of aortic stenosis
There are several degrees of aortic stenosis. Each of them corresponds to the level of development of abnormal valve changes. The more the hole is narrowed, the more difficult the treatment of the disease, and the more pronounced the symptoms. The following stages can be distinguished:
- insignificant;
- moderate;
- heavy.
At the first stage, the patient does not feel unwell. The disease occurs without any symptoms, and it can only be detected by listening to the heart: specific murmurs may be recorded. This stage does not require specific therapy.
The doctor may prescribe medication, but usually for preventive purposes or to treat a disease that has led to the development of stenosis. But due to the fact that this pathology has almost no manifestations, its presence is often discovered by chance.
The second degree is characterized by the appearance of certain symptoms. A person suddenly begins to feel tired, sometimes slightly dizzy, and shortness of breath appears. At this stage, it is possible to register pathological changes using electrocardiography or fluoroscopy. Data obtained from these studies often provide the basis for surgical intervention. This degree is also called hidden heart failure.
At the third stage, patients often experience angina. The symptoms are pronounced. Shortness of breath becomes more frequent, which can lead to fainting or presyncope. This stage in the course of the disease is very important. It is also called severe stenosis. By missing it and subjecting the patient to surgical treatment, it is possible to create conditions under which severe complications may be fatal.
Severe aortic stenosis
There are other stages of stenosis. If the necessary measures are not taken at the third stage, the main one of which is surgical correction aortic valve, the disease progresses and severe heart failure begins to develop. At this stage, the disease manifests itself in the same way as at the previous one. However, in addition to severe shortness of breath, regular attacks of suffocation are added, which occur mainly at night.
Lesions in the cardiac apparatus lead to disturbances in the functioning of other organs. The patient experiences pain in the chest area, hypotension, and drowsiness. Shortness of breath occurs even with minor physical exertion.
Pain may appear in the right precostal area. This pain is caused by impaired blood circulation in the liver. The drugs prescribed by the doctor at this stage of the disease can alleviate the general condition. The diet should exclude salt. Alcohol and smoking are not allowed in this condition. In most cases, surgery is contraindicated for patients at this stage of stenosis, although in some cases it is still performed.
There is also a terminal stage, in which drug treatment has no effect. It can only cause some improvements in the patient’s condition for a while. Edema syndrome appears. And since the likelihood of mortality with surgery at this stage is very high, surgery is absolutely contraindicated. All measures taken at the previous stages are designed to prevent the onset of the terminal stage of stenosis.
Aortic stenosis in children
This disease in most cases is acquired. But there are also congenital forms of stenosis, in which the formation of pathology begins in the prenatal period. In newborns with an abnormal change in the heart valve, a normal state is observed for some time: distal systemic blood flow is ensured by a patent ductus arteriosus. However, cyanosis may subsequently develop due to a large admixture of venous blood.
At a minor stage, the only manifestation may be a systolic murmur. This disease can be suspected in children with Williams syndrome, which results in hereditary rearrangement of chromosomes.
With the auscultation method, signs such as heart murmurs that differ from each other in tone are determined. In childhood, this pathology sometimes does not make itself felt and does not cause any pain, but later it can manifest itself.
The severity of this disease in children can vary from minor to severe. In the latter case, medical intervention is mandatory. The only way is surgical. Symptoms of aortic stenosis may be different.
The appearance of a person with aortic stenosis is characterized by general pallor. Pallor skin causes a tendency to peripheral vasoconstrictor reactions. In the later stages, on the contrary, acrocyanosis is observed, that is, a bluish coloration of the skin, which is explained by insufficient blood supply to small capillaries. In the severe stage, peripheral edema also appears. With percussion of the heart, the doctor determines the expansion of the boundaries up and down. The palpation method allows you to feel the displacement of the apical impulse and systolic tremor in the jugular fossa.
What diagnostic methods determine aortic stenosis?
Depending on the severity, the disease is diagnosed using methods such as phonocardiography, echocardiography, probing of the heart cavities and others.
- Phonocardiography. Auscultatory signs of aortic stenosis are specific rough sounds observed over the aorta and mitral valve. These changes can also be recorded with phonocardiography.
- Echocardiography. This ultrasound method allows you to determine the thickening of the aortic valve flaps and hypertrophy of the walls of the left stomach.
- Probing of the heart cavities is performed to determine the pressure gradient between the left ventricle and the aorta.
- Ventricolography is a study that is carried out to identify mitral insufficiency.
- Aortography provides differentiated diagnosis of aortic stenosis.
Symptoms of aortic stenosis can be different. They depend on the severity of the disease, which is determined by the systolic pressure gradient.
Depending on the stage of the disorder and diagnostic methods, the following are distinguished: stages of aortic stenosis :
- The initial degree of aortic stenosis is called complete compensation. This is the degree to which the disease can only be detected by auscultation, that is, by measuring blood pressure.The degree of narrowing of the aorta is still insignificant, so in many cases it is not detected at this stage.
- At the second stage or with hidden heart failure, fatigue and shortness of breath appear. ECG can determine aortic stenosis gradient pressure in the range of thirty-five centimeters. This indicator indicates the severity of the disease.
- The next stage is determined by an increase in the gradient to sixty-five centimeters. These data are indications for surgery . Symptoms at the third stage of the disease are also diagnosed as relative coronary insufficiency. An ECG allows you to determine the form of pathology.
- The fourth stage refers to severe heart failure. Symptoms: shortness of breath and asthma attacks, which occur mainly at night. At this stage, surgical intervention is excluded. To diagnose the disease at this stage, an electrocardiogram and chest x-ray are used.
- The last stage is terminal. In the terminal form of aortic stenosis, a person develops edema syndrome. ECG, X-ray and echocardiography are methods that allow us to identify the features of pathology at this stage. Surgery in this case it is contraindicated.
The doctor detects the first signs of the disease when measuring blood pressure. And they are expressed in specific noises in the chest area.
For moderate aortic stenosis, which corresponds to the second stage, the hole area ranges from 1.2 to 0.75 cm². The first signs of left ventricular hypertrophy appear, resulting in an increase in systolic pressure. This can lead to angina and coronary disease hearts. That is why at this stage great attention is given to drug prevention, which can prevent the development of these diseases.
Severe aortic stenosis (third degree) is expressed in a narrowing of the valve opening to 0.74 cm². If in the insufficient stage there are no significant hemodynamic disturbances, then characteristic feature severe form is the return of a significant part of the blood from the valve to the aorta.
This volume can be half of the total cardiac output. As a result, pressure is exerted on the ventricle, it undergoes deformation and hypertrophies. As a result of its overload, myocardial hypertrophy may develop. Damage to the left ventricle can also lead to mitral valve insufficiency.
Treatment of aortic stenosis
Even with an asymptomatic disease, the patient should be closely monitored by a cardiologist. Echocardiography is performed at least once a year. For this group of patients, doctors usually prescribe preventive antibiotics before dental procedures such as caries treatment and tooth extraction. Such drug treatment is preventive in nature and prevents the development of infective endocarditis.
During pregnancy, women with this diagnosis undergo careful monitoring of hemodynamic parameters. Severe aortic stenosis may be an indicator for termination of pregnancy.
- Drug therapy performs the following tasks:
- Eliminates arrhythmia;
- Provides prevention of coronary artery disease;
- Normalizes blood pressure;
- Slows the progression of heart failure.
Surgery for aortic stenosis
Surgery for aortic stenosis is indicated for the first clinical defects. Among them are the appearance of shortness of breath, anginal pain, and syncope. In this case, endovascular balloon dilatation of aortic stenosis can be used. However, in most cases, this procedure is not effective enough and may be accompanied by subsequent recurrence of stenosis.
For minor changes in the aortic valve leaflets, open surgical aortic valve repair is used. This type of surgical correction is usually used to treat aortic stenosis in children. .
Pediatric cardiac surgery also uses the Ross procedure. This surgery is performed to repair the valve. A balloon catheter is inserted into the heart through a peripheral vein. Having reached the goal, the cylinder begins to supply air, thereby expanding the hole in the valve. However, in some cases this procedure is not enough. If valve insufficiency is observed, there is a need for surgical treatment. Surgical therapy in the treatment of this disease involves replacing the damaged valve with either a pulmonary or artificial prosthesis.
The Ross operation allows you to eliminate all manifestations of stenosis and the consequences that it entails. The advantage of the replacement method heart valve pulmonary is that over time it will not deform and will retain its functions. The pulmonary valve, which served as a prosthesis, also needs to be replaced with something. It is replaced with an artificial or dead donor valve. Due to the complexity of this procedure, there are not many specialists in the world who can perform it. More heart transplants have been performed in world surgery than Ross operations.
Drug therapy
This type of treatment is carried out using the following drugs:
- dopaminergic drugs: Dopamine and Dobutamine;
- diuretics: Torasemide (Trifasa, Torsida);
- vasodilators: Nitroglycerin;
- antibiotics: Cephalexin, Cefadroxil.
Dopamine helps improve heart function: pressure in the aorta increases and blood circulates better.
Diuretics remove excess fluid from the body, which puts stress on the heart.
Nitroglycerin relieves pain
This treatment is prescribed if surgery can be avoided. It is aimed at eliminating symptoms and treating diseases that caused the development of stenosis. Drug therapy is also used in the preoperative and postoperative period.
Regardless of how the valve was implanted during surgery, prevention of the infectious disease endocarditis is strictly necessary. Previously, for these purposes in Russian medicine used the antibiotic biociocillin, which was administered intramuscularly. Today, preference is given to retarpen.
Prevention can last for several years, but can also be prescribed for life. But it is only necessary if surgery has eliminated valve damage caused by acute rheumatic fever.
After implantation of an artificial valve, lifelong use of blood thinning medications. This prophylaxis prevents the formation of blood clots. For more than a year now, warfavin has been the standard as the best anticoagulant.
- Elimination of physical activity;
- Limiting fluid and salt intake;
- Quitting alcohol and smoking;
- Exclusion from the diet of fatty and fried foods.
It is necessary to regularly take medications prescribed by a doctor and undergo the necessary diagnostic measures.
Doctor's instructions regarding actions during pregnancy may vary and depend on the degree of the disease. Severe aortic stenosis may be a reason for termination of pregnancy. This is explained by the fact that during the period of gestation, all organs begin to work in an enhanced mode and the cardiovascular system is no exception. In safer forms, pregnancy proceeds normally, but preventive measures are taken to prevent the development of valve pathology.
Conclusion
Forecast regarding consequences aortic valve stenosis without the necessary treatment is quite unfavorable. Surgical intervention significantly improves the clinical and hemodynamic picture. The survival rate of patients treated with surgery increases to seventy percent out of a hundred. This is a pretty good criterion for the level of cardiac surgery treatment.
Sincerely,
Aortic stenosis or stenosis of the aortic ostium is characterized by a narrowing of the outflow tract in the area of the semilunar valve of the aorta, which makes systolic emptying of the left ventricle difficult and the pressure gradient between its chamber and the aorta sharply increases. The share of aortic stenosis in the structure of other heart defects is 20–25%. Aortic stenosis is 3–4 times more common in men than in women. Isolated aortic stenosis is rare in cardiology - in 1.5-2% of cases; in most cases, this defect is combined with other valve defects - mitral stenosis, aortic insufficiency, etc.
Classification of aortic stenosis
By origin, congenital (3-5.5%) and acquired stenosis of the aortic mouth are distinguished. Taking into account 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 valve opening. With minor aortic stenosis of the first degree, the opening area is from 1.6 to 1.2 cm² (with the norm being 2.5-3.5 cm²); The systolic pressure gradient is in the range of 10–35 mmHg. Art. Moderate aortic stenosis of degree II is indicated when the valve opening area is from 1.2 to 0.75 cm² and the pressure gradient is 36–65 mm Hg. Art. Severe grade III aortic stenosis is noted when the area of the valve opening is narrowed to less than 0.74 cm² and the pressure gradient increases to more than 65 mm Hg. Art.
Depending on the degree of hemodynamic disturbances, aortic stenosis can occur in a compensated or decompensated (critical) clinical variant, and therefore there are 5 stages.
Stage I(full compensation). Aortic stenosis can only be detected by auscultation; the degree of narrowing of the aortic orifice is insignificant. Patients require dynamic monitoring by a cardiologist; surgical treatment is not indicated.
Stage II(latent heart failure). There are complaints of fatigue, shortness of breath with moderate physical activity, and dizziness. Signs of aortic stenosis are determined by ECG data and radiography, pressure gradient in the range of 36–65 mm Hg. Art., which serves as an indication for surgical correction of the defect.
Stage III(relative coronary insufficiency). Typically increased shortness of breath, angina, and fainting. The systolic pressure gradient exceeds 65 mmHg. 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 is already excluded in most cases; In some patients, cardiac surgery is potentially possible, but with less effect.
Stage V(terminal). Heart failure is steadily progressing, shortness of breath and edema syndrome are pronounced. Drug treatment achieves only short-term improvement; Surgical correction of aortic stenosis is contraindicated.
Causes of aortic stenosis
Acquired aortic stenosis is most often caused by rheumatic damage to the valve leaflets. In this case, the valve flaps are deformed, fuse together, become dense and rigid, leading to a narrowing of the valve ring. Causes of acquired aortic stenosis can also include atherosclerosis of the aorta, calcification (calcification) of the aortic valve, infective endocarditis, Paget's disease, systemic lupus erythematosus, rheumatoid arthritis, and end-stage renal failure.
Congenital aortic stenosis occurs when there is a congenital narrowing of the aortic mouth or a developmental anomaly - a bicuspid aortic valve. Congenital aortic valve disease usually appears before age 30; acquired - at an older age (usually after 60 years). Smoking, hypercholesterolemia, and arterial hypertension accelerate the formation of aortic stenosis.
Hemodynamic disturbances in aortic stenosis
With aortic stenosis, severe disturbances of intracardiac and then general hemodynamics develop. This is due to difficult emptying of the cavity of the left ventricle, due to 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 opening and the duration of the defect. Compensatory hypertrophy ensures long-term preservation of normal cardiac output, which inhibits the development of cardiac decompensation.
However, with 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 stroke volume and ejection fraction decrease, which is accompanied by myogenic left ventricular dilation, increased end-diastolic pressure and the development of left ventricular systolic dysfunction. Against this background, the pressure in the left atrium and pulmonary circulation increases, i.e., arterial pulmonary hypertension develops. In this case, the clinical picture of aortic stenosis may be aggravated by 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 noticeable discomfort for a long time. The first manifestations are associated with a narrowing of the aortic mouth to approximately 50% of its lumen and are characterized by shortness of breath during exercise, fatigue, muscle weakness, and a feeling of palpitations.
At the stage of coronary insufficiency, dizziness, fainting with a rapid change in body position, attacks of angina pectoris, paroxysmal (night) shortness of breath, and in severe cases - attacks of cardiac asthma and pulmonary edema occur. The combination of angina pectoris with syncope, and especially the addition of cardiac asthma, is unfavorable prognostically.
With the development of right ventricular failure, swelling and a feeling of heaviness in the right hypochondrium are noted. Sudden cardiac death with aortic stenosis occurs in 5–10% of cases, mainly in elderly people with severe narrowing of the valve opening. Complications of aortic stenosis may include infective endocarditis, ischemic disorders cerebral circulation, arrhythmias, AV block, 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 later stages, acrocyanosis may occur. Peripheral edema is detected in severe aortic stenosis. Upon percussion, the expansion of the borders of the heart to the left and down is determined; The displacement of the apical impulse and systolic tremor in the jugular fossa are palpably felt.
Auscultatory signs of aortic stenosis are rough systolic murmur above the aorta and above the mitral valve, muffled sounds of the first and second sounds in the aorta. These changes are also recorded during phonocardiography. According to the ECG, signs of left ventricular hypertrophy, arrhythmia, 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 lengthening of the arc of the left contour of the heart, a characteristic aortic configuration of the heart, post-stenotic dilatation of the aorta, signs pulmonary hypertension. Echocardiography reveals thickening of the aortic valve flaps, limitation of the amplitude of movement of the valve leaflets in systole, and hypertrophy of the walls of the left ventricle.
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 identify concomitant mitral regurgitation. Aortography and coronary angiography are used for differential diagnosis aortic stenosis with aneurysm of the ascending aorta and ischemic heart disease.
Treatment of aortic stenosis
All patients, incl. with asymptomatic, fully compensated aortic stenosis should be closely monitored by a cardiologist. They are recommended Echocardiography every 6-12 months. In order to prevent infective endocarditis, this group of patients requires preventive antibiotics before dental (treatment of caries, tooth extraction, etc.) and other invasive procedures. Management of pregnancy in women with aortic stenosis requires careful monitoring of hemodynamic parameters. The indication for termination of pregnancy is severe aortic stenosis or increasing signs of heart failure.
Drug therapy for aortic stenosis is aimed at eliminating arrhythmias, preventing coronary heart disease, normalizing blood pressure, and slowing the progression of heart failure.
Radical surgical correction of aortic stenosis is indicated at the first clinical manifestations defect - the appearance of shortness of breath, anginal pain, syncope. For this purpose, balloon valvuloplasty—endovascular balloon dilatation of aortic stenosis—can be used. However, this procedure is often ineffective and is accompanied by subsequent relapse of stenosis. For mild changes in the aortic valve leaflets (more often in children with congenital defects), open surgical repair of the aortic valve (valvuloplasty) is used. In pediatric cardiac surgery, the Ross operation is often performed, which involves transplanting the pulmonary valve into the aortic position.
If indicated, plastic surgery of supravalvular or subvalvular aortic stenosis is performed. The main treatment method for aortic stenosis today remains aortic valve replacement, in which the affected valve is completely removed and replaced with a mechanical analog or xenogeneic bioprosthesis. Patients with a prosthetic valve require lifelong anticoagulants. In recent years, percutaneous aortic valve replacement has been practiced.
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The essence of aortic stenosis
The weak link of the systemic circulation (from the left ventricle blood flows through the aorta to all organs) is the tricuspid aortic valve at the mouth of the vessel. When it opens, it allows portions of blood into the vascular system, which the ventricle pushes out during contraction and, when closed, prevents them from moving back. It is in this place that characteristic changes in the vascular walls appear.
With pathology, the tissue of the valves and aorta undergoes various changes. These can be scars, adhesions, connective tissue adhesions, calcium salt deposits (hardening), atherosclerotic plaques, congenital valve malformations.
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, when speaking about aortic stenosis, this form of the disease is usually meant.
Pathology very rarely (in 2%) appears as an independent disease; most often it is combined with other defects (mitral valve) and diseases of the cardiovascular system (coronary heart disease).
Causes and risk factors
Characteristic symptoms
For decades, stenosis occurs without showing any signs. In the early stages (before the lumen of the vessel closes by more than 50%), the condition may manifest itself as general weakness after serious physical activity (sports training).
The disease progresses gradually: shortness of breath appears with moderate and basic exercise, accompanied by increased fatigue, weakness, and 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 aortic narrowing:
- shortness of breath (first with severe and moderate exertion, then at rest);
- weakness, fatigue;
- painful pallor;
- dizziness;
- sudden loss of consciousness (with a sudden change in body position);
- chest pain;
- disturbance of heart rhythm (usually ventricular extrasystole, a characteristic sign is a feeling of interruptions in work, “loss” of a heartbeat);
- swelling of the ankles.
The appearance of pronounced signs of circulatory disorders (dizziness, loss of consciousness) greatly worsens the prognosis of the disease (life expectancy no more than 2–3 years).
After narrowing the lumen of the vessel by 75%, cardiovascular failure quickly progresses and becomes more complicated:
Aortic valve stenosis can cause sudden death without any external manifestations and preliminary symptoms.
Treatment methods
It is impossible to completely 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%);
- does not manifest itself with severe symptoms of circulatory disorders (shortness of breath after moderate physical activity);
- Diagnosed by listening to murmurs over the aorta.
Treatment goals:
In later stages, drug therapy is ineffective, the patient's prognosis can only be improved with the help of surgical methods treatment (balloon dilatation of the aortic lumen, valve replacement).
Drug therapy
The attending physician prescribes a set of medications individually, taking into account the degree of stenosis and symptoms of concomitant diseases.
The following medications are used:
| Group of drugs | Name of the drug | What effect do they have? |
|---|---|---|
| Cardiac glycosides | Digitoxin, strophanthin | Reduce heart rate, increase their strength, the heart works more efficiently |
| Beta blockers | Coronal | Normalize heart rhythm, reduce the frequency of ventricular extrasystoles |
| Diuretics | Indapamide, veroshpiron | Reduce the volume of fluid circulating in the body, reduce blood 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 late stages (the lumen of the vessel is more than 75% closed), surgical intervention is contraindicated in most cases (80%) due to the possible development of complications (sudden cardiac death).
Balloon dilatation (expansion)
Aortic valve plastic surgery
Aortic valve replacement
Ross prosthetics
Lifelong patient:
- is registered with a cardiologist;
- undergoes examination at least twice a year;
- after prosthetics, he constantly takes anticoagulants.
Prevention
Prevention of acquired stenosis comes down to eliminating possible reasons and risk factors for the development of pathology.
Necessary:
For patients with cardiovascular pathologies, the optimal balance of potassium, sodium, and calcium in the diet is of great importance, so the diet should be discussed with your doctor.
Forecast
Aortic stenosis has been asymptomatic for decades. The prognosis depends on the degree of narrowing of the artery lumen - reducing the diameter of the vessel to 30% does not complicate the patient’s life. At this stage, regular examinations and monitoring by a cardiologist are indicated. 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 vessel is blocked by more than 50%, the appearance of attacks of angina pectoris (a type of coronary artery disease) and sudden fainting. Heart failure progresses rapidly, becomes complicated and greatly reduces the patient's life expectancy (from 2 to 3 years).
Congenital pathology ends in death in 8–10% of children in the first year of life.
Timely surgical treatment improves the prognosis: more than 85% of those operated on survive for up to 5 years, and 70% for more than 10 years.
okardio.com
Causes
Congenital narrowing of the aorta occurs due to an abnormal development of the fetus - the bicuspid valve. This developmental defect usually appears before the age of 30.
Acquired stenosis usually manifests itself at the age of over 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 aortic stenosis (incidence about 60%).
- Supravalvular (10%).
Depending on the severity, there are 3 degrees of the disease:
- 1 – the opening of the vessel at the point of narrowing has an area in the range of 1.2-1.6 cm2. (normal size is 2.5-3.5), and the gradient (that is, the difference) of pressure in the heart (its left ventricle) and the vessel (aorta) is 10-35 mmHg.
- 2 – the values of these indicators are 0.75-1.2 cm2. and 35-65 mmHg. respectively.
- 3 – area up to 0.75 cm2, gradient over 65 mmHg.
According to the degree of disturbances caused by aortic stenosis of the heart, there are 2 paths of the disease:
- Compensated.
- Decompensated (or critical).
Stages of development and symptoms of aortic stenosis
Depending on the severity and severity of symptoms, there are 5 stages of disease development:
- The easiest one. The narrowing of the vessel is insignificant. There are no symptoms. And stenosis is detected by listening (auscultation). Observation by a cardiologist without special treatment is indicated. The first stage is called full compensation.
Characterized by the following symptoms:
With this degree, the diagnosis is made on the basis of an ECG and/or radiography. The identified gradient was 35-65 mmHg. 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.
- Severe shortness of breath.
- The appearance of angina (attacks of pain in the heart due to insufficient blood supply to the heart muscle).
With a gradient greater than 65 mmHg. mandatory surgical treatment is necessary.
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, increased diastolic pressure, cyanosis (blueness) of the face.
Attacks are relieved using nitroglycerin, painkillers, antihypertensives (pressure-reducing), diuretics, bleeding, applying tourniquets to the veins of the extremities and oxygen therapy. In some cases, surgical correction is possible, but less effective than with stages 1-3 of aortic stenosis.
Heart failure is progressing. Shortness of breath is constant, edema syndrome is pronounced. The use of medications relieves symptoms for a short time. Surgery at this stage is contraindicated.
Treatment
- Monitoring by a cardiologist - patients must undergo examination every 6 months, including in the first stage of stenosis.
- Drug treatment is aimed at normalizing the blood supply to the heart, eliminating arrhythmia, regulating blood pressure, and relieving symptoms of heart failure.
- Surgical treatment of aortic stenosis (carried out in the absence of contraindications):
Endovascular balloon dilatation is a percutaneous intervention that enlarges 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 some time 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.
Ross operation – used in pediatric cardiac surgery. It involves transplanting a valve from the pulmonary artery to the place of the aortic one.
Aortic valve replacement – the valve is completely removed and an artificial prosthesis is inserted in its place.
With timely surgical treatment and constant monitoring, the risk fatal outcome for patients with aortic stenosis is significantly reduced.
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When they talk about narrowing of the aorta, one must always clearly know where the narrowing is. It can be at the mouth of the aorta, in the area of the conus arteriosus sinister, in the area of the trunk of the ascending aorta and in the area of the descending aorta, at the site of the so-called isthmus of the aorta, located between the origin of the left subclavian artery and the place where the ductus botallus enters the aorta.
Stenoses of the aortic mouth have been known in the literature since 1817, but they were studied in particular detail by K. A. Rauchfus in 1869. Descriptions of coarctation of the aorta have appeared since 1760. Stenoses of the aortic mouth are relatively rare, but Rauchfus observed 10 cases, V. P. Zhukovsky - 7, and Theremin - 42.
According to the literature, the longest life expectancy with occlusion of the aortic mouth is 27 weeks, but most patients die much earlier, during the first weeks of life.
Aortic stenosis occurs as a result of changes in the aortic valves - thickening and fusion of them, which leads to a more or less significant narrowing of the valve opening. Behind the narrowing of the opening there may be a post-stenotic dilatation of the aorta. Sometimes there is a combination of aortic cone stenosis with stenosis in the valve area. The clinical picture of this form will resemble that of acquired aortic stenosis.
A peculiar form is represented by congenital narrowing in the area of the aortic arch, especially at the point of transition of the aortic arch into the descending part immediately behind the place of origin of the subclavian artery. This form of narrowing of the aorta has been known since 1791 and is known as coarctation or aortic isthmus stenosis. This area of the aortic arch normally has a physiological narrowing in children that does not give any symptoms. But with more severe narrowing, the lumen of the aorta can decrease to several millimeters in diameter.
There are two types of narrowing of the aortic isthmus: adult and pediatric.
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 aortic isthmus stenosis, narrowing is observed closer to the isthmus, in an area of 4-5 cm, most often before the attachment of the ductus botallus, which usually remains open. This is important because it allows unimpeded compensatory blood flow from the pulmonary artery to the descending aorta below the site of narrowing. Depending on the location of the narrowing and the degree of narrowing, the clinical picture will vary significantly.
For children's type of isthmus stenosis clinical symptoms are detected very early. If the stenosis is severe, then at birth the child exhibits cyanosis and dyspnea and dies soon after birth. With a lesser degree of stenosis, initially no symptoms are observed, but later a gray-ashy coloration of the skin, shortness of breath and swelling of the lower extremities are revealed. The heart rapidly dilates and a systolic murmur is heard at the base on the right. When measuring blood pressure, it appears to be higher in the upper extremities than in the lower extremities. Pulse on femoral artery weaker and palpable in the presence of an open ductus arteriosus. Also characteristic is the difference in the degree of oxygen saturation of the blood in the upper and lower half of the body, 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 botallus.
With the adult type of narrowing, the clinical picture is more polymorphic. For a long time there may be no symptoms. There are known cases of detection of stenosis of the aortic isthmus 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 complain of headaches, dizziness, palpitations, and nosebleeds. Shortness of breath easily appears, manifesting itself in some cases as typical crises, true attacks of suffocation, during which the face and limbs become cyanotic and consciousness is lost. These attacks are especially typical for children in the first 2 years of life. Upon examination, attention is drawn to coldness of the lower extremities, sometimes leg cramps, and intermittent claudication. Sometimes there is a visible heartbeat in the fifth intercostal space, slightly to the left of the nipple line. During percussion, the left border of the heart extends beyond the nipple line, right border- behind the right edge of the sternum. Systolic tremor 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 heart area, which intensifies as it approaches the base of the heart, reaching its maximum intensity in the second intercostal space on the right.
The noise is transmitted with equal force to the back into the interscapular space and into the subclavian region. Sometimes the noise is long-lasting, intensifies during systole and weakens during diastole. This peculiarity of noise depends on the presence of a ventricular septal defect or on an open ductus botellus or greatly dilated collaterals. Sometimes there is no noise. The second sound of the aorta is preserved, sometimes accentuated. The radial artery pulse is regular, small, and the same on both sides. The jugular artery pulse lags behind the radial artery pulse 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. The difference in blood pressure in the arteries of the upper and lower extremities is also characteristic. In the arteries of the lower extremities, decreased systolic and diastolic pressure is noted. The difference can be 10-30 mmHg. Art.
With increased stress on the heart, a much higher rise in blood pressure (up to 100 mm) can be observed than normal (20-30 mm).
When the aortic isthmus narrows, there is a slightly increased oxygen capacity with an increase in O2 content in arterial blood and a decrease in 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 area of the anterior lateral surface of the chest at the level of the intercostal spaces, on the back, on the back surface of the shoulder, one can notice the development of vessels in the form of cords, forming 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 project up to the epigastrium.
This collateral network is not constant, it can be more or less noticeable depending on the state of the cardiovascular system.
The adult type of aortic isthmus stenosis differs from the pediatric type in the powerful development of collaterals, since in the pediatric type, due to better blood supply to the lower half of the body, there are fewer reasons for the formation of collateral circulation.
Sometimes it is possible to notice a difference in the filling of the vessels of the neck and upper extremities, which are clearly palpable and pulsate intensely, and the vessels of the abdominal cavity and lower extremities, which are barely palpable. This difference depends on the degree of stenosis and the degree of development of collaterals.
Congenital narrowing of the aortic isthmus is often accompanied by insufficiency of the aortic valves, which causes diastolic tremors at the base of the heart.
Electrocardiographically, a pronounced levogram and sometimes distortion of the T wave are determined, indicating damage to the heart muscle.
X-rays show enlargement of the heart, mainly to the left, and strong pulsation. Sometimes an enlargement of both the right ventricle and atrium is detected. The first left arch is usually small, with moderate protrusion. In an oblique position, a slight protrusion and pulsation of the arch of the descending aorta is determined. When radiography is performed in a posteroanterior position, dilatation of the left supraclavicular artery can often be observed. In many cases, it is possible to note the presence of usurs in the area of the posterior parts of the upper and lower ribs in the form of semilunar notches facing downwards. They are formed due to increased pressure from pulsating arterial collaterals on the lower edge of the ribs.
An angiocardiographic diagnosis of aortic narrowing can best be made using a left anterior oblique view. But intravenous administration 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 permissible, i.e., injecting it directly into the aortic system near the site of narrowing. In this case, the degree and location of narrowing of the aorta, breaks in the aortic arch, the presence of the arteriovenous duct, abnormalities of the branches of the aortic arch and the collateral network are more clearly revealed. It is also highly desirable to remove the heart after the injection of a contrast agent into the esophagus (esophagogram) both during ventricular systole and diastole to recognize the location of the aortic arch in relation to the esophagus.
Due to the fact that vasography does not in all cases provide an impeccable diagnosis of aortic stenosis, it is suggested to resort to thoracoscopy with examination of the anterosuperior mediastinum. On the left along the anterior axillary line, a thoracoscope is inserted into the fourth intercostal space, a pneumothorax is applied and the aortic arch and the origin of the subclavian artery are examined. left branch pulmonary artery and left atrial appendage. After the intervention, the air is aspirated back.
The prognosis for mildly expressed narrowing of the adult-type 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. Rarely, 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 childhood type are little 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 6-15 years old and provides a significant improvement in both the general condition and blood supply to the lower half of the body. With the improvement of surgical techniques, the indications for operations are expanding. Surgery before the age of 6 years is not beneficial, because children still have few collaterals, a very narrow aorta, and anastomosis is difficult. Mortality during surgery is estimated at approximately 10-15%.
Surgical intervention for children's type of aortic stenosis is difficult, because with it the area of narrowing of the aorta is larger.
Vice or violation anatomical structure heart - invariably leads to a deterioration in the functioning of the entire body.
Moreover, if this defect interferes with the normal activity of the largest artery circulatory system– the aorta, which supplies blood to all internal organs and systems. We are talking about aortic valve stenosis or aortic stenosis.
Aortic stenosis is a change in the structure of the aortic valve in such a way that the normal conduction of blood from the heart to the aorta is disrupted. As a result blood supply to most internal organs and systems of the human body deteriorates, “connected” to big circle blood circulation
Among other valvular heart defects, aortic stenosis is the second most common after: 1.5-2% of people of retirement age suffer from this disease, most of them (75%) are men.
In any healthy person, at the border of the left ventricle of the heart and the aorta, which originates from it, there is tricuspid valve- a kind of “door” that allows blood from the heart into the vessel and does not let it back out. Thanks to this valve, which is at least 3 cm wide when fully opened, blood flows from the heart to the internal organs in only one direction.
For various reasons, this valve may not begin to open completely; its opening becomes overgrown with connective tissue and narrows. As a result, the ejection of blood from the heart into the aorta decreases, rather than being released through the vessels blood stagnates in the left ventricle, which gradually leads to its increase and stretching.
The human heart thus begins to work in an abnormal mode, in it congestion worsens– all this has the most negative impact on overall health.
ICD-10 code for congenital aortic valve stenosis:
ICD-10 code for acquired aortic valve stenosis:
What happens to the body?
With aortic valve stenosis, the aorta will change: its valve contracts or tissue scarring occurs in it, eventually developing stenosis. In the heart, when the aortic valve does not function properly, blood flow is disrupted, resulting in the development of a defect.
The disease is manifested by angina attacks of the heart; blood flows to the brain with disruptions, which causes migraines and loss of orientation in space. As a result of the fact that blood is delivered to the aorta in small quantities, the pulse slows down, systolic pressure decreases, and diastolic pressure is either normal or increased.
What is aortic stenosis - just about the complex ones in the video:
What happens to blood pressure and why?
Ideally, the aortic opening is approximately 4 cm². With stenosis, it becomes narrower, and as a result, blood flow in the left ventricle becomes difficult. In order not to disrupt the normal functioning of the body, the heart is forced to work harder and increase the pressure in the chamber of the left ventricle so that blood moves freely through the narrowed lumen of the aorta. As blood enters the aorta, pressure increases. In addition, systole time is mechanically prolonged.
Such work of the heart does not go unpunished. An increase in systolic pressure causes an increase in the muscles (myocardium) of the left ventricle. Diastolic pressure increases.
What is the orifice area and what happens to it depending on the stage?
The dimensions of the valve opening show how much the aortic lumen is reduced. Normally, the area indicators are 2.5-3.5 cm². Conventionally, the dimension of the lumen can be divided into stages:
- A slight stenosis is determined, the lumen is from 1.6 to 1.2 cm².
- Moderate stenosis (from 1.2 to 0.75 cm²).
- Severe stenosis - the lumen decreases to 0.74 cm² or less.
Causes and risk factors
The disease can be congenital or acquired. Each type should be considered separately.
Congenital
This condition develops in the fetus in the first third of pregnancy. More often it is abnormal development valve Congenital heart disease can be diagnosed immediately after birth, but this is rare. Often, blood circulation begins to deteriorate by age 30.
Acquired
The acquired form of the disease develops for various reasons. The classic provocateurs of this disease are:
- organic damage to the valve leaflets due to rheumatic diseases – 13-15% of cases;
- – 25%;
- aortic valve calcification – 2%;
- infectious inflammation of the inner lining of the heart or endocarditis – 1.2% (more about infective endocarditis — ).
As a result of all these pathological influences there is a violation of the mobility of the valve flaps: they grow together, become overgrown with connective scar tissue, calcify – and stop opening completely. This is how a gradual narrowing of the aortic opening occurs.
In addition to the above reasons, there are risk factors, the presence of which in the anamnesis significantly increases the likelihood of aortic valve stenosis:
- genetic predisposition to this defect;
- hereditary pathology of the elastin gene;
- diabetes;
- renal failure;
- high cholesterol;
- smoking;
- hypertension.
Classification by degree
The disease is classified:
- According to the location of the narrowing: supravalvular, subvalvular and valvular.
- According to the degree of narrowing.
The disease is divided into stages according to severity. This is important to determine the correct treatment. In medicine, it is customary to divide stenosis as follows:
- Easy— full compensation, the narrowing is insignificant, doctors observe the dynamics, surgery is not required. The hole area was reduced by less than half. There are no clinical symptoms. Pathology can only be discovered by chance.
- Moderate- hidden heart failure; shortness of breath, fatigue after minor work, dizziness develops; The disease is detected by radiography and ECG. Surgical correction is often necessary. Clinical signs of the disease are very nonspecific (weakness, dizziness, tachycardia), while the area of the hole has already decreased by almost 50%.
- Expressed— relative coronary insufficiency; shortness of breath is observed after minor exertion, angina pectoris is present, and often loss of consciousness. The first specific signs of heart failure appear. The hole has shrunk by more than 50%. Requires surgery.
- Heavy- severe heart failure, asthmatic symptoms at night, shortness of breath even in calm state. Surgery is contraindicated. The only way out is cardiac surgery, which produces only minor improvements.
- Critical— terminal stage, the disease progresses, all manifestations become more pronounced. Irreversible changes. Medication therapy only provides temporary improvements. Heart surgery is strictly contraindicated.
Critical form
Doppler echocardiography can detect critical aortic stenosis. The area of the hole at this stage of stenosis is less than 0.8 cm 2. Complications and changes in organs are very serious. Severe swelling, shortness of breath, and dizziness are added to the existing manifestations. Feeling worse.
Men over 40 years of age and women over 50 years of age undergo coronary angiography. Conservative therapy provides only temporary relief. But there are cases when restoration of a vascular branch occurs with mandatory medical monitoring of the dynamics of the action of certain drugs. Surgical intervention is unacceptable, as there is a high risk of death.
In combination with valvular insufficiency
Aortic valve stenosis is characterized by weakening of the contractile functions of the left cardiac ventricle, which causes aortic insufficiency.
Symptoms of this combination are:
- severe shortness of breath;
- feeling of lack of air, especially at night;
- the functioning of other systems and the body is disrupted;
- pressure decreases;
- one feels constant fatigue and drowsiness.
Pathology is detected using an ECG, in which there are signs of left ventricular hypertrophy, arrhythmia, blockade. On an x-ray you can see changes in the shape of the heart. Echocardiography helps diagnose an increase in the size of the valve flaps, disturbances in the amplitude of movement of the valve leaflets, and thickening of the walls.
Selected medications can reduce the manifestation of stenosis; surgery is contraindicated at this stage of development.
Degenerative stenosis
A similar condition is found in older patients who have not had rheumatic or infectious diseases. Calcium salts are deposited on the valve leaflets and calcification occurs.
The disease is asymptomatic for a long time. Even doctors make completely different cardiac diagnoses. Only additional examination by X-ray, ECG, EchoCG can reveal pathology.
How complications can manifest themselves:
- Blockage of blood vessels with lime chips.
- Severe arrhythmia.
Conservative treatment is indicated when the narrowing does not exceed 30%. Surgery is not recommended if the lumen is reduced by more than 75% due to the high percentage of deaths.
Danger and complications
According to medical research after the first pronounced clinical symptoms of the disease appear and until the patient dies, no more than 5 years will pass if the disease is not treated.
The greatest danger of aortic stenosis is progressive hypoxia of all internal organs, with the development of irreversible degenerative changes in them.
Typical complications of the disease are:
- heart rhythm disturbances incompatible with life;
- the occurrence and development of secondary mitral stenosis;
- acute heart failure;
Symptoms and signs, frequency of occurrence
The first pronounced symptoms of heart disease appear when the lumen of the aorta is closed by at least half. Compensatory capabilities human hearts are so large that until this moment the disease is practically asymptomatic: a person may feel tired, he is often dizzy, but he is unlikely to associate these ailments with heart disease.
The patient may experience shortness of breath after physical exertion, and sometimes experience chest pain and palpitations. If the area of the aortic opening increases to 0.75-1.2 cm², then the symptoms become more distinct. These include the following:
- shortness of breath - at first only after physical exertion, and as the disease worsens, even at rest;
- weakness, fainting and presyncope;
- pallor of the skin – the so-called “aortic pallor”;
- muscle weakness;
- slow and barely palpable pulse;
- tachycardia and chest pain that radiates between the shoulder blades, into the arm or shoulder;
- frequent headaches;
- hoarseness of voice;
- swelling of the face and legs;
- dry suffocating cough.
- abdominal pain and ascites (fluid accumulation in the abdominal cavity).
If aortic stenosis reaches 0.5 - 0.75 cm2, then this condition is called severe stenosis and is considered critical. Signs of the disease appear even in normal conditions. The person develops heart failure. It appears as follows:
- Swelling of the lower extremities is pronounced, spreading to the legs, thighs and feet.
- Sometimes swelling spreads to the abdomen and the entire body of a person.
- Shortness of breath is accompanied by attacks of suffocation.
- The skin color becomes marbled and even bluish, this is especially noticeable on the face and fingers (acrocyanosis).
Hemodynamic angina appears constant pain in heart. The overall incidence ranges from 2 to 7% of cases.
In newborns
Stenosis in infants is congenital. It appears as follows:
- the baby becomes lethargic;
- has difficulty taking the breast;
- the skin on the face, hands and feet becomes bluish.
Pathology is observed in 8% of cases, and much more often in boys. The task of parents is to identify such violations as early as possible and seek medical help. If a heart murmur is observed during listening, additional diagnosis of the disease will be required.
In children and adolescents
Often in childhood, pathology develops due to hereditary predisposition. The disease begins to actively manifest itself between the ages of 11 and 15 years. The disease can be suspected by shortness of breath, increased heartbeat and pain in the chest area.
In old people
In old age, the disease worries many people; according to statistics, up to 20% of old people. The symptoms are the same as in patients of other ages. Due to the deterioration of the body at this age, fainting is not uncommon. This circumstance alone should prompt an elderly person to see a doctor. Occurs
Considering that the first characteristic symptoms of aortic stenosis appear quite late, when the disease has long passed its initial stage, contacting a cardiologist should be immediate if they are detected.
Diagnostics
IN clinical practice Aortic stenosis can be difficult to differentiate from other types of stenosis and defects.
During the examination of the patient, the doctor uses the following diagnostic methods:
| Diagnostic tool | Signs of aortic stenosis |
| Medical history examination | characteristic complaints and a history of provoking diseases |
| Visual inspection | specific pallor without cyanosis, swelling of the face, weakness of muscles and pulse, enlarged liver, symptoms of pulmonary congestion |
| Auscultation of the heart | murmur in the aortic valve area, moist rales in the lungs |
| Laboratory methods for studying biological materials | inflammatory urine and blood tests |
| Electrocardiography | may be uninformative for quite a long time, later signs of left ventricular enlargement appear |
| Ultrasound of the heart with Doppler | changes in the leaflets and valve openings, thickening of the walls of the left ventricle, changes in blood flow speed |
| Radiography | specific “aortic” change in the contours of the heart, change in the pulmonary pattern |
| Cardiac catheterization and coronary angiography | invasive diagnostic techniques that are used before surgery and accurately record the area of narrowing of the hole and changes in pressure in the chambers of the heart |
Ultrasound signs
If you do a Doppler ultrasound of the heart organ, you can see the following:
- The valve flaps change.
- The left ventricular walls thicken.
- There is a change in the speed of blood flow.
Echocardiographic signs of aortic stenosis are discussed in this video:
Also find out why it is dangerous and how it differs from other acquired defects from a separate material.
You can read all about pulmonary valve atresia and its danger to the life of a newborn in this.
Find out what symptoms accompany Ebstein's anomaly.
Treatment regimen
The possibilities of conservative medical (without surgery) treatment of aortic valve stenosis are limited, since it has virtually no effect on the pathological mechanism of narrowing of the valve lumen.
Without surgery
Drug therapy is used only to prevent possible complications and relief of symptoms of the disease. For this purpose the following is prescribed:
- dopaminergic drugs (Dopamine, Dobutamine);
- vasodilators (Nitroglycerin);
- cardiac glycosides (Digoxin, Strophanthin);
- antihypertensive drugs (lisinopril);
- antibiotics for the prevention of endocarditis.
Medicines that improve general well-being are also prescribed (diuretics - to remove fluid, to eliminate pain - nitroglycerin and other vasodilators).
Once a year or more often you should undergo preventive examinations see a cardiologist to identify the development of complications. The question of how long you can do without surgery is impossible to answer unequivocally. With the help of drug therapy, hemodynamics can be slightly improved. If the condition worsens, surgery will be recommended.
In any case, the best effect is achieved by surgical intervention, which is best performed before the failure of the left ventricle of the organ develops.
Indications for performance and applied operations
Surgery is indicated in cases of moderate or severe stenosis or if clinical symptoms are present. As mentioned above, surgical treatment must be performed before the development of left ventricular failure, otherwise complications will begin. The operation can be performed if the narrowing of the lumen has not reached 75%.
Aortic stenosis grade 3-4 or stenosis with severe left ventricular dysfunction – direct reading to surgery.
The following types of surgical intervention are practiced:
- Balloon valvuloplasty- a minimally invasive radical method in which the aortic mouth is expanded by pumping air into a special balloon brought to the desired location through the main vessel.
The method is rarely used in cases of acquired disease - mainly in preparation for subsequent open surgery, in elderly and weakened patients. A mechanical enlargement of the hole in the area of the valve leaflets is carried out using a special cylinder. Penetration into the chest cavity is not required, which means this method is non-traumatic. The technique is often used on infants and children. It is performed with moderate stenosis (narrowing 50-75%).
- Ross prosthetics. The operation involves inserting a balloon catheter, which supplies air and expands the lumen of the valve.
- Plastic surgery of fused valve leaflets on an open heart. A complex operation that requires connection to a heart-lung machine. Rarely practiced. This operation involves the use of special devices made of metal, biomaterial or silicone to correct the aortic opening. It is carried out for minor violations in the valve leaflets (30-50%).
- Aortic valve replacement (replacement). The prosthesis is either an artificial material made of silicone or metal, or a biomaterial taken from one’s own or donor artery.
The operation is performed for severe stenosis (narrowing more than 75%). A currently widely practiced method of radical treatment of aortic stenosis. It can even be used to treat elderly people and gives good results in severe cases of the disease.
How is a valve replaced?
There are open and endovascular prosthetics. In an open type of operation, the patient undergoes preparatory stage: the patient is given sedatives one day before; half a day before surgery, the patient is prohibited from taking food or taking any medications. The operation is performed under general anesthesia and lasts up to 6 hours..
Valve replacement occurs as follows: the chest is cut and opened, the patient is connected to a machine to support life, the old valve is removed and a prosthesis is installed instead, then the machine is turned off and the chest is closed with sutures.
During endovascular prosthetics, the chest is not opened - small incisions are made between the ribs. But this method is just coming into practice and is used quite rarely.
Duration of the rehabilitation period, is it possible to cure forever?
Rehabilitation will depend on the severity of the disease. If the operation was successful, then on the second day the person is allowed to get up. On the fifth day he can be discharged. If postoperative treatment is indicated, the patient will have to stay in the ward for 10 days.
The average recovery period lasts three weeks. But in the subsequent period of life you will have to follow all the doctor’s recommendations.
It is worth remembering that when replacing or plasticizing the aortic valve, only the defect is eliminated, but the problem remains.
Treatment can be conservative or surgical. Clinical drug therapy involves the use of medications such as:
- dopaminergic agents;
- diuretics, which are more often called diuretics;
- vasodilators, for example, nitroglycerin;
- taking antibiotics.
All medications are taken only as prescribed by a doctor and in a strictly prescribed dosage.
Prognosis and survival
If the disease is diagnosed on initial stage, That after the operation, the 5-year survival prognosis will be 85%, 10-year – 70%. If the disease is in an advanced stage, the prognosis is reduced to 5-8 years of life. In newborns, death occurs in 10% of cases.
If the area of the vessel opening is within 30%, then the patient feels quite satisfactory and can manage for many years simply under the supervision of a cardiologist. The age of the patient plays an important role - the younger the patient, the greater his chances for a normal, long and fulfilling life.
Isolated aortic stenosis with proper treatment, gives a favorable prognosis for the future. Patients with this disease can remain able to work for a long time, while limiting their physical activity.
Surgical intervention for this pathology almost always guarantees a favorable outcome. Mortality, even with severe disease in weakened patients, does not exceed 10% in this case.
All patients, regardless of treatment methods and results, you need to reconsider your lifestyle in favor of:
- restrictions on physical labor;
- giving up bad habits;
- salt-free diet.
Useful video
Learn about aortic valve stenosis from the video:
It must be remembered that aortic stenosis, after the first clinical signs appear, does not give a person much time to think and search for alternative, gentle treatment methods. The decision in favor of life in this case is to immediately seek help from a cardiologist and agree to surgery if necessary. This is the only way the patient will be protected from death in the next few years.
