Aortic insufficiency: causes, survey, therapy

Author: Strokina OA, therapist, doctor of functional diagnostics.
September 2019.

ICD-10 code: I35.0, I06.8, I35.8.

Aortic insufficiency - disruption of the aortic valve to form a reverse current blood from the aorta into the left ventricular cavity. Symptomatology depends on the amount of blood falling back into the ventricle. pathology diagnosis is possible only by means of echocardiography (ultrasound of the heart). Treatment also depends on the degree of deficiency and may imply both medical and surgical techniques.

Aortic insufficiency - heart disease, which is characterized by the development of regurgitation (reverse blood flow) in the aortic valve in the relaxation phase of the cardiac muscle. As a result, the blood from the aorta into the ventricle falls again. There is an overflow of its capacity, which in the future may face the expansion of the cavity of the left chambers of the heart with the development of heart failure.

In phase reducing the left ventricle ejects blood into the aorta, followed by a ventricular relaxation phase. At this point, the blood tends to go back. The way it block 3 aortic valve, which represent the "bags". In the course of filling with blood, straightened flaps interlock with each other and completely close the aortic orifice.

At the mitral and tricuspid valves normally assume a small discharge of blood in the opposite direction, wherein the term "failure" is not used. In the case of aortic valve regurgitation is minimal even pathology, for which you want to watch.

Prevalence

Aortic insufficiency is more common in older people. According to research by about 20-30% of people over 65 years suffer from this disease. This is explained by the high incidence of atherosclerosis, Calcification (calcium deposits on the valves), rheumatic heart disease, which are peculiar to it at an older age. Young rarely suffer from aortic insufficiency.

Causes and risk factors

Aortic valve insufficiency develops due to the loose folds closing the phase of ventricular relaxation that can occur for several reasons:

• idiopathic (unknown cause) expanding aorta;
• congenital aortic valve (usually bicuspid aortic valve);
• sclerosis flaps (due to atherosclerosis);
• rheumatism;
• infective endocarditis;
• arterial hypertension;
• myxomatous degeneration (a developmental disorder of the connective tissue);
• separation of the ascending aorta;
• Marfan syndrome;
• trauma of aortic valve;
• ankylosing spondylitis;
• syphilitic aortitis;
• rheumatoid arthritis.

Most of these reasons lead to chronic aortic insufficiency, which may be a long time, asymptomatic. Others, such as infective endocarditis, aortic dissection, trauma is often accompanied by a sharp development of aortic insufficiency, severe. This leads to serious violations of hemodynamics. As a result, the blood in much smaller quantity is reached to vital organs: brain, kidney, liver, heart.

Types and step

For aortic insufficiency doctors use classification by the severity of regurgitation (reverse blood flow). degree only determines the physician on the results of functional diagnostics echocardiography:

• Mild (mild);
• moderate;
• Expressed.

There are many ways to define it. But they are all possible thanks to the Doppler study. This function have all devices for echocardiography. It can detect abnormal flow within the heart by means of an ultrasonic sensor. Anyway this is the most objective assessment of the severity of aortic insufficiency.

Also isolated by acute or chronic failure. It is mostly clinical classification based on symptoms and their rate of development.

Symptoms of aortic regurgitation

The rate of development of symptoms depends on the cause of formation of aortic insufficiency.

The acute form

Acute aortic insufficiency develops rapidly, within minutes, hours, at least - during the day. The reason is often some kind of acute-onset disorders, such as valve or aortic dissection injury. As a result develop severe aortic regurgitation with a large reverse shunt into the left ventricle. He becomes full volume. Rapidly developing mitral insufficiency and there is stagnation of blood in the pulmonary circulation, which can lead to pulmonary edema. In the case of emergency measures heart can recover almost completely.

In the acute form develops acute heart failure with pulmonary edema, and cardiogenic shock:

• pronounced shortness of breath,
• shortness of breath,
• cough,
• forced position of the patient sitting,
• wheezing in the lungs,
• the appearance of a pink frothy sputum,
• Blood pressure reduction up to the loss of consciousness.

Even with intensive medical therapy often death occurs from ventricular arrhythmias, cardiogenic shock, pulmonary edema.

The chronic form

Chronic develops slowly. The clinic does not develop for years. Man can not know about the disease and failure is often a random finding. Or the patient has already drawn with any symptoms when the heart is changed. Treatment in this case is mainly symptomatic. Although in some cases, surgical correction is possible.

Chronic aortic regurgitation may be asymptomatic for years. Early symptoms may be lethargy, loss of efficiency, and fainting presyncopal state. Gradually developing clinical heart failure due to left ventricular volume overload:

• dyspnea on exertion, then eventually - alone;
• asthma;
• pain in the heart of pressing, squeezing character passes after taking nitroglycerin;
• lower extremity edema, and further in the absence of adequate treatment liquid appears in the peritoneal, pleural and pericardial cavities even;
• heart rhythm disturbances - from atrial fibrillation to ventricular tachycardia. life-threatening.

survey

Examination of the patient always starts with its inspection and auscultation of the heart. Already at this stage, the doctor is able to be suspected by the presence of valvular heart murmur. It is also possible to reduce the diastolic (lower limit) of blood pressure and in consequence - increase the pulse pressure (difference between the upper and lower boundaries of the blood pressure). However, these signs of aortic insufficiency detected only in patients with chronic disease, when it is clearly manifested clinical heart failure described above.

Instrumental methods - the only way to find regurgitation in the aortic valve.

Echocardiography (ultrasound of the heart)

The diagnostic method of the first line. It allows you to detect reverse flow of blood through the aortic valve. The doctor determines the extent of its severity, and the possible reason - for example, injury to the vegetation valve (accumulation of bacteria on valves - sign infective endocarditis), the volume of the left chambers of the heart, left ventricular ejection fraction and a plurality of other morphological and functional performance ..

Magnetic resonance imaging (MRI)

It used only on condition that echocardiography is not available or the visualization of the heart and its structures is extremely difficult.

Multislice computed tomography angiography and magnetic resonance imaging angiography (both procedures with contrast) used in patients with bicuspid aortic valve, to assess the initial aorta to its arc, but only if the results of echocardiography unsatisfactory.

Chest X-ray

Used to evaluate the size of the heart and the ascending aorta.

Electrocardiogram (ECG)

Reveals arrhythmias, conduction in the heart and signs of myocardial hypertrophy.

These methods are more than enough to make an accurate diagnosis of aortic insufficiency and start treatment on time.

Treatment

Treatment of aortic insufficiency is engaged cardiologist and cardiovascular surgeon.

medication

Drug treatment is prescribed depending on the cause of occurrence of aortic insufficiency. It is viewed as a variant of the preparation for surgery or for reducing the symptoms heart failure and alleviate the condition of patients who have a contraindication to surgical treatment.

In rheumatoid arthritis and infective endocarditis is prescribed a course of antibiotic therapy. In the first case as prevention of disease exacerbation used penicillin antibiotics (benzylpenicillin benzathine). When the infective endocarditis usually prescribed long course of 2 weeks, amoxicillin, ceftriaxone, gentamicin, vancomycin less. Drugs are prescribed based on the clinical and bacterial resistance to them. It can be used as a drug and the complex.

Treatment of hypertension comprises administering ACE inhibitor (perindopril, enalapril, lisinopril) or sartans (valsartan, losartan) and calcium antagonists dihydropyridine (nifedipine, amlodipine).

Beta-blockers (bisoprolol, metoprolol, nebivolol) was added to the treatment in the event of reduced cardiac ejection fraction based on the results of echocardiography.

Surgery

Aortic valve - the only possible method for valve adjustment.

It is recommended in patients with:

• severe aortic regurgitation and the presence of symptoms regardless of ejection fraction;
• asymptomatic chronic severe aortic regurgitation and ejection fraction less than 50%;
• chronic aortic regurgitation in parallel with the operation of aorto-coronary bypass surgery or aortic, and other heart valves;
• asymptomatic severe aortic regurgitation with normal ejection fraction. a significant expansion of the left ventricle (EDD - more than 75 mm).

Timing patients with aortic insufficiency vary greatly depending on the severity of the condition and the cause of the pathology. After the operation, we recommend a course of rehabilitation in a sanatorium or cardiological rehabilitation center. Recovery time - a minimum of 3 months, after which the patient can return to work to resolve the doctor.

complications

Complications of aortic insufficiency develop by increasing its severity. At the beginning may appear normal syncope (fainting) due to insufficient blood supply to the brain. Disturbances in the form of conduction blockade left bundle branch block and atrioventricular bundle of impulse conduction may also frequently occur in patients with aortic insufficiency.

Coronary insufficiency aortic can accompany, but usually in conjunction with aortic valve stenosis. The patient developed seizures angina (Crushing heart pain, compressive nature) and even heart attack infarction.

Heart failure - the most common complication of already severe aortic insufficiency. The patient complains of shortness of breath on exertion, attacks of breathlessness, swelling of the lower extremities.

Sudden death often occurs as a result of life-threatening arrhythmias - paroxysmal ventricular tachycardia, ventricular fibrillation. In this case the person does not even have time to call the ambulance - so quickly develops an arrhythmia.

Forecast

Prediction of aortic insufficiency is better, the less the degree of regurgitation and the sooner treatment is started. Preventive examination by a physician, cardiologist, full antibiotic treatment in case of infective endocarditis and rheumatic fever - all contribute to a better prognosis. It is important to listen to yourself, your body, not to miss the first symptoms (fatigue, decreased performance, fainting, shortness of breath on exertion).

Usually, when the forecast worsens as irreversible changes in the structure of the heart severe heart failure clinic.

prevention

To prevent the development of an exacerbation of acute rheumatic fever in patients with rheumatic aortic stenosis recommended antibiotic therapy (penicillin G benzathine).

Use of warfarin as an anticoagulant recommended for patients who delivered a mechanical prosthetic aortic valve. It prevents the formation of blood clots in the new valve, the isolation which can result a stroke. In the treatment of warfarin requires INR control levels within 2-3. Exact numbers will tell the attending physician.

In patients with a biological prosthesis recommend taking aspirin 75-100 mg.

Operated patients with persistent reduced left ventricular ejection fraction is assigned lifelong therapy of cardiac insufficiency.