20.10.2021

Treatment of aortic insufficiency

Mild aortic insufficiency with asymptomatic treatment does not require. It is recommended to limit physical exertion, annual examination of a cardiologist with echocardiography. In asymptomatic moderate aortic insufficiency, diuretics, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers are prescribed. In order to prevent infection during the conduct of dental and surgical procedures, antibiotics are prescribed.

Surgical treatment – plastic / aortic valve replacement is indicated for severe symptomatic aortic insufficiency. In the case of acute aortic insufficiency due to the dissection of the aneurysm or aortic injury, aortic valve replacement and the ascending aorta are performed.

Signs of inoperability are an increase in LV diastolic volume up to 300 ml; ejection fraction of 50%, the final diastolic pressure of about 40 mm Hg. Art.

Aortic insufficiency (aortic valve insufficiency) is a valve defect in which the semilunar valves of the aortic valve do not fully close during diastole, resulting in diastolic blood regurgitation from the aorta back to the left ventricle. Among all heart defects, isolated aortic insufficiency accounts for about 4% of cases in cardiology; in 10% of cases, aortic valve insufficiency is combined with other valve lesions. The vast majority of patients (55-60%) have a combination of aortic valve insufficiency and aortic stenosis. Aortic insufficiency is 3-5 times more common in males.

Aortic insufficiency is an incomplete closure of the aortic valve cusps during diastole, leading to a reverse flow of blood from the aorta to the left ventricle. Aortic insufficiency is accompanied by dizziness, fainting, chest pain, shortness of breath, frequent and irregular heartbeat. Chest radiography, aortography, echocardiography, electrocardiogram, MRI and CT of the heart, cardiac catheterization, etc. are used to make the diagnosis of aortic insufficiency. The treatment of chronic aortic insufficiency is done conservatively (diuretics, ACE inhibitors, calcium channel blockers, etc.); in case of severe symptomatic course, plastic surgery or aortic valve replacement is indicated.

Causes of aortic insufficiency

Aortic insufficiency is a polyetiological defect, the origin of which may be due to a number of congenital or acquired factors.

Congenital aortic insufficiency develops when there is one, two, or four-leaved aortic valves instead of three-leaved. The causes of aortic valve defect are hereditary diseases of the connective tissue: congenital aortic wall pathology – aortic-ectasia, Marfan syndrome, Ehlers-Danlos syndrome, cystic fibrosis, congenital osteoporosis, Erdheim disease, etc. In this case, incomplete closure or prolapse of the aortic valve usually occurs.

The main causes of acquired organic aortic insufficiency are rheumatism (up to 80% of all cases), septic endocarditis, atherosclerosis, syphilis, rheumatoid arthritis, systemic lupus erythematosus, Takayasu’s disease, traumatic valve damage, etc.

Rheumatic lesion leads to thickening, deformation and wrinkling of the aortic valve cusps, as a result of which they are not fully closed during the diastole period. Rheumatic etiology usually underlies the combination of aortic insufficiency with mitral defect. Infective endocarditis is accompanied by deformation, erosion, or perforation of the cusps, causing aortic valve defect.

The occurrence of relative aortic insufficiency is possible due to the expansion of the fibrous ring of the valve or the lumen of the aorta in hypertension, Valsalva sinus aneurysm, stratifying aortic aneurysm, ankylosing rheumatoid spondylitis (Bechterew disease), and other pathologies. Under these conditions, a separation of the aortic valve leaflets during the diastole may also occur.

Hemodynamic disorders in aortic insufficiency

Hemodynamic disorders in aortic insufficiency are determined by the volume of diastolic blood regurgitation through a valve defect from the aorta back into the left ventricle (LV). At the same time, the volume of blood returning to LV can reach more than half of the amount of cardiac output.

Thus, in aortic insufficiency, the left ventricle during the diastole period is filled both as a result of blood supply from the left atrium and as a result of aortic reflux, which is accompanied by an increase in diastolic volume and pressure in the LV cavity. The volume of regurgitation can reach up to 75% of the stroke volume, and the end diastolic volume of the left ventricle can increase to 440 ml (at a rate of 60 to 130 ml).

The expansion of the cavity of the left ventricle contributes to the stretching of muscle fibers. For the expulsion of increased blood volume, the force of ventricular contraction increases, which, with a satisfactory condition of the myocardium, leads to an increase in systolic ejection and compensation for altered intracardiac hemodynamics.

However, long-term work of the left ventricle in the hyperfunction mode is invariably accompanied by hypertrophy and then cardiomyocyte dystrophy: a short period of LV tonogenic dilatation with an increase in blood outflow is replaced by a period of myogenic dilatation with increased blood flow. As a result, mitralization of the malformation is formed – the relative insufficiency of the mitral valve, caused by dilatation of the left ventricle, dysfunction of the papillary muscles and expansion of the fibrous ring of the mitral valve.

Under conditions of aortic insufficiency compensation, the function of the left atrium remains intact. With the development of decompensation, there is an increase in diastolic pressure in the left atrium, which leads to its hyperfunction, and then – hypertrophy and dilatation. Stagnation of blood in the vascular system of the pulmonary circulation is accompanied by an increase in pressure in the pulmonary artery, followed by hyperfunction and right ventricular myocardial hypertrophy. This explains the development of right ventricular failure with aortic defect.

Classification of aortic insufficiency

To assess the severity of hemodynamic disturbances and the compensatory abilities of the organism, a clinical classification is used, highlighting 5 stages of aortic insufficiency:

  • I – full compensation stage. Initial (auscultatory) signs of aortic insufficiency in the absence of subjective complaints.
  • II – the stage of latent heart failure. Characterized by a moderate decrease in exercise tolerance. According to ECG, signs of hypertrophy and volume overload of the left ventricle are detected.
  • III – stage of subcompensation of aortic insufficiency. Typical anginal pain, forced restriction of physical activity. On the ECG and radiographs – left ventricular hypertrophy, signs of secondary coronary insufficiency.
  • IV – stage of decompensation of aortic insufficiency. Severe shortness of breath and attacks of cardiac asthma occur at the slightest tension, an increase in the liver is determined.
  • V – terminal stage of aortic insufficiency. It is characterized by progressive total heart failure, deep dystrophic processes in all vital organs.
Symptoms of aortic insufficiency

Patients with aortic insufficiency in the stage of compensation do not report subjective symptoms. Latent blemish can be long – sometimes for several years. The exception is acutely developed aortic insufficiency due to dissecting aortic aneurysm, infective endocarditis, and other causes.

Symptoms of aortic insufficiency usually manifest with sensations of pulsation in the vessels of the head and neck, increased heartbeats, which is associated with high pulse pressure and an increase in cardiac output. Sinus tachycardia characteristic of aortic insufficiency is subjectively perceived by patients as a rapid heartbeat.

With a pronounced defect in the valve and a large volume of regurgitation, cerebral symptoms are noted: dizziness, headaches, tinnitus, visual disturbances, short-term syncope (especially when the horizontal position of the body quickly changes to the vertical one).

Subsequently, angina pectoris, arrhythmia (extrasystole), shortness of breath, increased sweating. In the early stages of aortic insufficiency, these sensations are disturbed mainly during exercise, and later they appear at rest. Accession of right ventricular insufficiency manifests itself edema in the legs, heaviness and pain in the right hypochondrium.

Acute aortic insufficiency occurs by the type of pulmonary edema, combined with arterial hypotension. It is associated with a sudden volume overload of the left ventricle, an increase in the end-diastolic pressure in the LV, and a decrease in shock output. In the absence of special cardiac surgery, mortality in this condition is extremely high.

Diagnosis of aortic insufficiency

Physical data for aortic insufficiency are characterized by a number of typical symptoms. On external examination, pallor of the skin is noteworthy, and in the later stages acrocyanosis. Sometimes there are external signs of increased pulsation of the arteries – “dancing carotid” (visible pulsation on the carotid arteries), Musset’s symptom (rhythmic nodding his head to the beat of the pulse), Landolfi symptom (pulsation of the pupils), Quincke capillary pulse (pulsation of the nail bed vessels) ), Muller’s symptom (pulsation of the uvula and the soft palate).

Typically, the visual definition of the apical impulse and its displacement in the VI – VII intercostal space; the aortic pulsation is palpable behind the xiphoid process. Auscultative signs of aortic insufficiency are characterized by diastolic noise on the aorta, weakening of I and II heart sounds, “accompanying” functional systolic noise on the aorta, vascular phenomena (double tone Traube, double noise Duroze).

Instrumental diagnostics of aortic insufficiency is based on the results of ECG, phonocardiography, X-ray examinations, EchoCG (CLE), cardiac catheterization, MRI, MSCT. Electrocardiography reveals signs of left ventricular hypertrophy, with mitralization of the defect – data for left atrial hypertrophy. With the help of phonocardiography, altered and abnormal heart sounds are determined. An echocardiographic study reveals a number of characteristic symptoms of aortic insufficiency – an increase in the size of the left ventricle, an anatomical defect, and a functional failure of the aortic valve.

On radiographs of the chest revealed an expansion of the left ventricle and the shadow of the aorta, the apex of the heart to the left and down, signs of venous congestion in the lungs. With ascending aortography, blood flow regurgitation through the aortic valve into the left ventricle is visualized. Probing of cardiac cavities in patients with aortic insufficiency is necessary to determine the magnitude of cardiac output, the final diastolic volume in the LV and the volume of regurgitation, as well as other necessary parameters.

Prognosis and prevention of aortic insufficiency

The prognosis of aortic insufficiency is largely determined by the etiology of the defect and the volume of regurgitation. In severe aortic insufficiency without decompensation, the average life expectancy of patients from the time of diagnosis is 5-10 years.

In the decompensated stage with symptoms of coronary and heart failure, drug therapy is ineffective, and patients die within 2 years. Timely cardiac surgery significantly improves the prognosis of aortic insufficiency.

The prevention of the development of aortic insufficiency consists in the prevention of rheumatic diseases, syphilis, atherosclerosis, their timely detection and proper treatment; clinical examination of patients at risk for the development of aortic defect.

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