13. Syndromes of valvular heart disease.

Valvular heart defects are acquired, less often congenital morphological changes in the valvular apparatus, leading to a violation of its function and hemodynamics. Two periods in the clinical course of heart defects:

• compensation period (without the development of heart failure)

• decompensation period (with the development of heart failure)

Mitral valve insufficiency

With mitral valve insufficiency, the function of the valve apparatus is impaired, which is characterized by incomplete closure of the valves of the bicuspid valve during systole and the absence of a period of closed valves.

REASONS: rheumatic endocarditis (in 75% of cases), infectious endocarditis, atherosclerosis, trauma, systemic diseases of the connective tissue, myocardial infarction with rupture of the papillary muscles, congenital splitting of the mitral valve cusps, relative mitral valve insufficiency (with aortic defects, arterial hypertension, myocarditis myocardial dystrophy, cardiosclerosis, subaortic muscle stenosis), mitral valve prolapse.

1. Complaints: There are no complaints at the compensation stage. In the decompensated phase - shortness of breath, palpitations, interruptions and pain in the heart, with congestion in the lungs - coughing, hemoptysis.

2. Palpation - apical impulse is displaced to the left, spilled;

3. Percussion - an increase in the boundaries of relative dullness to the left, and in the case of a sharp increase in the left atrium - and up. During decompensation (Kitaev’s reflex) - expansion to the right;

4. During auscultation, weakening of the I tone, systolic murmur at the apex, decreasing a different timbre, is brought to the left axillary region or to the second and third intercostal space to the left of the sternum, takes more than ½ systole, amplifies in the exhalation phase and on the left side, a moderately pronounced accent II tone on the pulmonary artery (Kitaev's reflex);

5. ECG: signs of left atrial hypertrophy (―P mitrale‖) and left ventricle, during decompensation (Kitaev’s reflex) - right ventricular hypertrophy;

6. FCG: confirms auscultation data;

7. X-ray: an increase in the left departments of the heart (ventricle and atrium), the heart acquires a mitral configuration, the displacement of the contrasted esophagus along an arc of large radius (in the left lateral projection). During decompensation (Kitaev’s reflex) - expansion to the right;

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8. Echocardiography: expansion of the cavities of the left ventricle and left atrium, multidirectional movement of the cusps of the mitral valve, their thickening and lack of closure in systole, pulmonary hypertension;

8. Doppler echocardiography: a turbulent flow of blood into the left atrium according to the degree of regurgitation.

Pic 3.21 Mitral insufficiency (hemodynamics)

Mitral stenosis

- narrowing of the left atrioventricular foramen.

REASONS: most often - acute rheumatic fever (rheumatic endocarditis); rarely - systemic diseases of the connective tissue (rheumatoid arthritis, systemic lupus erythematosus), mitral valve calcification.

Complaints: There are no complaints during the compensation period.

During decompensation: shortness of breath, hemoptysis, palpitations, interruptions and pain in the heart, with severe decompensation - swelling on the legs, pain in the right hypochondrium, an increase in the abdomen;

Ortner's symptom - a sharp increase in the left atrium can cause a violation of swallowing (compression of the esophagus) and hoarseness in connection with compression of the recurrent nerve.

1. Examination: acrocyanosis, cyanotic blush in the form of a ―butterfly‖ (―mitral‖ face), poor physical development, infantilism, ―heart hump‖.

2. Palpation: positive cardiac impulse, diastolic trembling ("cat purr") at the apex.

3. Percussion: the boundaries of relative and absolute dullness are shifted up and to the right (due to hypertrophy of the left atrium and right ventricle);

4. Auscultation: Amplification of the I tone at the apex (―clapping‖ I tone), ―mitral click‖ or tone of opening the mitral valve. The combination of ―clapping‖ I tone, II

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tone and tone of opening of the mitral valve creates a peculiar melody of a three-membered rhythm - ―quail rhythm‖. Based on the heart, emphasis and bifurcation of the II tone on the pulmonary artery. At the apex, diastolic noise is heard locally, without irradiation, sometimes with a presystolic amplification. On the pulmonary artery, you can listen to diastolic murmur (Graham-Steel noise);

5. The pulse is small, often the pulse is different - on the left radial artery is weaker than on the right (Popov's symptom), arrhythmia is possible (usually, atrial fibrillation);

5. HELL - a downward trend;

Pic 3.22 Mitral stenosis, hemodynamics

7. ECG: signs of left ventricular hypertrophy (―P mitrale‖) and right ventricle, atrial fibrillation (a specific symptom for mitral stenosis);

7. FCG: confirms the signs of auscultation;

7. X-ray - ―mitral configuration‖ of the heart: flatness of the waist, an increase in the left atrium, determined by the deviation of the esophagus contrasted with barium in the left lateral projection (along an arc of small radius), hypertrophy of the right ventricle, often the bulge of the pulmonary artery arch;

7. Echocardiography: unidirectional movement of the anterior and posterior cusps of the mitral valve forward, the rate of early diastolic closure of the anterior cusp and the amplitude of its movement is reduced, thickening of the valve, expansion of the cavity of the right ventricle and left atrium, reduction of the diameter of the mitral orifice.

Pic 3.23 Mitral configuration of the heart:

mitral stenosis (a), mitral insufficiency (b)

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Stenosis of the aortic orifice

REASONS: rheumatic endocarditis, infectious endocarditis, aortic atherosclerosis, congenital

aortic stenosis, syphilis.

SIGNS:

1. Complaints: there are no complaints in the compensation stage.

With decompensation - weakness, dizziness, fainting, heart pain, angina pectoris;

2. Inspection - pallor of the skin, visible mucous membranes, increased apical impulse;

2. Palpation: the apical impulse is displaced to the left, diffuse, resistant, high, ―raising‖, systolic trembling (―cat purr‖) in the second intercostal space to the right of the sternum - palpation analogue of systolic murmur;

2. Percussion - an increase in the left border of relative dullness, an expansion of vascular dullness in the second intercostal space to the right (post-stenotic expansion of the ascending aorta);

2. Auscultation: I tone at the apex is weakened, II tone at the aorta is weakened, gross systolic murmur on the aorta (maximum point), which is carried out on the carotid arteries and in the interscapular region, often above the entire surface of the heart, is better heard in a horizontal position on the exhale;

2. Pulse slow (pulsus parvus), rare (pulsus rarus), small (pulsus tardus), systolic and pulse blood pressure decreased;

2. ECG: signs of severe left ventricular hypertrophy;

3. FCG: consistent with auscultatory picture;

2. Echocardiography: reducing the amplitude of systolic opening, thickening, limiting the mobility of the valves of the aortic valve. Hypertrophy of the left ventricular myocardium, a decrease in the area of the aortic opening, dilatation of the ascending aorta (post-stenotic expansion) are clearly visible;

2. X-ray: "aortic" configuration of the heart due to concentric hypertrophy of the left ventricle. Often you can see calcification of the aortic valve, expansion of the initial part of the aorta;

2. Doppler echocardiography: a significant increase in the maximum velocity of blood flow through the mouth of the aorta.

2. With mitralization of the defect (the development of relative mitral valve insufficiency due to

dilatation of the left ventricle and expansion of the mitral orifice), it is possible to expand the borders of the heart to the right, due to hypertrophy of the right ventricle of the heart.

Pic 3.24 Aortic stenosis (hemodynamics).

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Aortic valve insufficiency

REASONS: acute rheumatic fever (rheumatic endocarditis), infectious endocarditis, syphilis, diffuse connective tissue diseases, trauma, atherosclerosis.

SIGNS: There are no complaints during the compensation period.

1. Complaints of headache, dizziness, tendency to fainting, sensation of tremors and pain in the heart area of angina pectoris;

2. Examination - pallor of the skin and mucous membranes, increased pulsation of the carotid arteries ("carotid dance"), synchronization with the pulse of the carotid arteries, shaking of the head (Musse symptom), pseudocapillary pulse (Quincke symptom), narrowing of the pupil during systole, expansion - with diastole (symptom of Landolfi);

Muller's symptom is the rhythmic pulsation and expansion of the tongue and tonsils.

3. Palpation - spilled, resistant, rising, domed apical impulse in the VI - VII intercostal space, shifted to the left and down, sometimes, pulsation in the II intercostal space on the right;

4. Percussion: an increase in the boundaries of relative dullness to the left, an increase in the width of the vascular bundle in the second intercostal space;

5. Auscultation: I tone at the apex is weakened, II tone on the aorta is weakened with rheumatic defect, with syphilitic and atherosclerotic defect II is sonorous (sometimes with a metallic tinge). A rough diastolic murmur is heard over the aorta, which is conducted to the Botkin-Erb point and amplified in the upright position of the patient. Flint's presystolic murmur is possible at the apex (due to relative mitral stenosis). Rarely, on the femoral artery is the double tone of Traube and when pressed with a stethoscope is the double noise of Vinogradov-Durozier.

6. The pulse is fast, high, large, jumping, rapid (P. celer, altus, magnus, salviens, frequencies);

7. Blood pressure: systolic - increased, diastolic - decreased, pulse - increased.

8. ECG: signs of hypertrophy and overload of the left ventricle and relative coronary insufficiency;

9. FCG: confirms auscultation data;

10. X-ray: dilatation and hypertrophy of the left ventricle, aortic configuration of the heart with an emphasized waist, expansion of the aorta in both directions;

11. Echocardiography: a change in the valve cusps, bacterial vegetation on the valve with infectious endocarditis, dilatation of the left ventricle, hyperkinesis of its walls, vibration of the

anterior cusp of the mitral valve during the diastole.

Pic 3.25 Aortic valve insufficiency (hemodynamics).

Pic 3.26 Aortic heart configuration:

Aortic stenosis (a,b); Aortic insufficiency (c)

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