Narrowing of the vessels of the aorta. aortic stenosis

Aortic valve disease ranks second in frequency after mitral valve disease among all acquired heart defects. In most cases, there is a combination of aortic stenosis with aortic valve insufficiency, while aortic stenosis is much less common in isolated form.

The aortic valve is made up of connective tissue and consists of three leaflets that open as blood moves from the left ventricle to the aorta (one of the largest blood vessels in the body, providing oxygenated 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 mouth of the aorta (the place where the aorta exits the left ventricle) affects the valve leaflets, this leads to the development of cicatricial changes in them and to the formation of a 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 obstacle is created in the way of blood flow to the aorta, which affects the supply of arterial blood to vital important organs and the whole organism.

Allocate congenital and acquired aortic stenosis. In turn, congenital stenosis is supravalvular, valvular and subvalvular, and acquired is almost always localized in the valves (valvular stenosis). Below we review 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 past bacterial endocarditis (more often in young people). In the elderly, the development of atherosclerotic plaques on the walls of the aorta, as well as the deposition of calcium salts in valve leaflets affected by atherosclerosis, can lead to stenosis of the aortic orifice.

Symptoms of aortic stenosis

The basis of clinical signs is a violation of hemodynamics (blood flow) both inside the heart and throughout the body. In the aorta, and, consequently, in all internal organs, the blood flow is much less than in a normally working heart. This is manifested by symptoms such as frequent dizziness, pale skin, fainting, deep fainting, muscle weakness, pronounced fatigue, sensations strong blows hearts.

Owing to the fact that muscle mass the left ventricle increases to overcome resistance to blood flow (left ventricular hypertrophy occurs), and the coronary (own heart) vessels are unable to provide the heart muscle with oxygen, angina pectoris develops. At the same time, the patient is disturbed by bouts of retrosternal pain, radiating to left hand or in the shoulder blade, occurring during exercise or at rest.

As the heart muscle of other chambers of the heart (left atrium, right ventricle) grows, due to its inability to cope with resistance, there are signs of blood stagnation in the vessels of the lungs, liver, muscles, kidneys and other organs. At the same time, the patient is disturbed 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 supine position with bubbling shortness of breath), pain in the right hypochondrium, an increase in the abdomen due to accumulation in abdominal cavity fluid, swelling of the lower extremities. Rhythm disturbances are much less common than with mitral defects, and, as a rule, are more often recorded. ventricular extrasystole.

All of these symptoms manifest themselves differently depending on the stage of the process.

Yes, in compensation stages the heart copes with the increased load on it, and symptoms do not appear for some period of time (for example, for decades, if the defect developed in young age and the degree of narrowing is not very pronounced).

AT subcompensation stages(hidden heart failure) symptoms appear when performing significant physical activity, especially not familiar to the patient.

AT stages of decompensation- severe heart failure, severe heart failure and terminal - the above symptoms disturb the patient not only when performing the minimum household load, but also at rest.

AT 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 by chance during a routine examination of the patient. If there are complaints from the heart, the diagnosis is established in accordance with the following research methods:

- clinical examination: complaints, medical history and appearance the patient, as well as auscultation (listening) of the chest, in which the doctor catches a rough systolic murmur at the projection point of the aortic valve - in the second intercostal space to the right of the sternum, wet rales in the lungs due to stagnation of blood in them, if any;
- laboratory research methods: when holding general analyzes blood and urine, biochemical and immunological blood tests reveal signs inflammatory process eg, repeated rheumatic attacks or indolent bacterial endocarditis; signs of impaired liver and kidney function; signs of lipid metabolism disorders in atherosclerosis - an increase in cholesterol levels, an imbalance of high and low density triglycerides, etc.;
- instrumental methods research: ECG is performed (single or daily monitoring according to indications), phonocardiography (FCG is a research method that allows you to convert sound signals heart murmurs into electrical ones, register them on photographic paper and conduct a more complete analysis of sound phenomena in heart defects), chest x-ray, echocardiography (ultrasound of the heart). Ultrasound of the heart is the only non-invasive (without introduction into body tissues) methods that allow you to clarify the diagnosis. When conducting this method the number, structure, thickness and mobility of the leaflets, the degree of narrowing of the valve opening with the measurement of its area, the degree of hemodynamic disturbances - left ventricular hypertrophy 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 ejection fraction (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:
1 degree - slight stenosis - the area of ​​​​the opening of the valve ring is more than 1.6 square meters. cm.
Grade 2 - moderate stenosis - the area is 0.75 - 1.6 square meters. cm.
Grade 3 - 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, while a slight stenosis corresponds 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 of blood flow, the higher pressure in the left ventricle and less in the aorta, which adversely affects the walls of the ventricle and the blood supply to the whole organism.

Treatment of aortic stenosis

The choice of the optimal method of treatment is determined individually by the attending physician for each individual patient. Medications, aortic valve surgery, and a combination of both 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 slow 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 should be notified about the occurrence 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), firstly, is ineffective, and secondly, it is fraught with a sharp decrease in pressure up to the development of a collapse with a restriction of 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 degree of stenosis and the presence of hemodynamic disorders and/or clinical manifestations. With moderate stenosis, valvuloplasty (dissection of adhesions and adhesions in the valve leaflets) can be used, and with severe stenosis, especially if it is combined with insufficiency, valve replacement is possible (replacing it with an artificial mechanical or biological prosthesis).

Replacement of the aortic valve with a mechanical prosthesis

Lifestyle in aortic stenosis

Compliance with lifestyle recommendations for this defect is not much different from other cardiovascular diseases. The patient must exclude physical activity, limit fluid and salt intake, give up alcohol, smoking, fatty, fried, cholesterol-rich foods. It is also necessary to constantly and regularly take prescribed medications and visit the attending physician with the necessary diagnostic measures.

In the event of pregnancy with aortic stenosis, the doctor's tactics for maintaining pregnancy depends 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 due to the fact that during the gestation of the fetus, the load on the circulatory system of the pregnant woman increases, and this can lead to a deterioration in hemodynamic parameters, the development of complications from the mother and fetus (the 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, dystrophic irreversible changes occur in the heart muscle, lungs, brain, liver, kidneys and other organs, which leads to 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 quite likely that complications that threaten a person’s life will develop - fatal heart rhythm disturbances (for example, ventricular fibrillation, complete atrioventricular blockade, ventricular tachycardia), sudden cardiac death, acute heart failure, systemic thromboembolism (release of blood clots in the vessels of the lungs, heart, brain, intestines, femoral arteries).

Complications can develop not only as a result of a long-term aortic stenosis, but also during aortic valve surgery, in particular, the development 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 their possible release into the blood vessels, disorders heart rate, the occurrence of re-stenosis (restenosis) in the late postoperative period as a result of repeated rheumatic attacks. Prevention of such complications is the lifelong intake of anticoagulants and antiplatelet agents - drugs that "thinn" the blood and prevent increased thrombosis, for example, chimes, warfarin, clopidogrel, aspirin and many others. In addition, the development of infectious complications is prevented by the appointment of antibiotics in the early surgical period and during medical and diagnostic manipulations and minor operations in the subsequent life of the patient, for example, when extracting a tooth, examining the bladder with its catheterization, abortion, and so on.

Forecast

The prognosis without treatment is poor. 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.

Therapist Sazykina O.Yu.

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

Classification of aortic stenosis

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

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

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

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

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

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

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

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

Causes of aortic stenosis

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

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

Hemodynamic disturbances in aortic stenosis

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

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

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

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

Symptoms of aortic stenosis

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

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

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

Diagnosis of aortic stenosis

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

Auscultatory signs of aortic stenosis are coarse systolic murmur over the aorta and over mitral valve, muffled I and II tones on the aorta. These changes are also recorded during phonocardiography. According to the ECG, signs of left ventricular hypertrophy, 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 an elongation of the arc of the left contour of the heart, a characteristic aortic configuration of the heart, post-stenotic dilatation of the aorta, and signs of pulmonary hypertension. On echocardiography, thickening of the aortic valve flaps, limitation of the amplitude of movement of the valve leaflets in systole, hypertrophy of the walls of the left ventricle is determined.

In order to measure the pressure gradient between the left ventricle and the aorta, probing of the heart cavities is performed, which makes it possible to indirectly judge the degree of aortic stenosis. Ventriculography is necessary to detect concomitant mitral regurgitation. Aortography and coronary angiography are used for 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 to conduct echocardiography every 6-12 months. In order to prevent infective endocarditis, this contingent of patients needs preventive antibiotics before dental (caries treatment, tooth extraction, etc.) and other invasive procedures. Pregnancy management in women with aortic stenosis requires careful monitoring of hemodynamic parameters. The indication for termination of pregnancy is a severe degree of aortic stenosis or an increase in signs of heart failure.

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

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

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

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The essence of aortic stenosis

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

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

Due to these changes:

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

Aortic stenosis can be:

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

Pathology very rarely (in 2%) appears as an independent, most often it is combined with other defects (mitral valve) and diseases of cardio-vascular system(coronary artery disease).

Causes and risk factors

Characteristic symptoms

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

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

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

Common symptoms of narrowing of the aorta:

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

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

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

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

Treatment Methods

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

Drug therapy is prescribed in the early stages of stenosis:

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

Treatment goals:

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

Drug therapy

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

The following medicines are used:

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

Surgery

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

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

Balloon dilatation (expansion)

Aortic valve repair

Aortic valve replacement

Ross prosthetics

Patient for life:

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

Prevention

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

Necessary:

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

Forecast

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

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

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

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

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Causes

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

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

Classification

There are several signs of classification of aortic stenosis:

Depending on the origin, aortic stenosis is distinguished:

Depending on the location of the narrowing:

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

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

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

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

• Compensated.
• Decompensated (or critical).

Stages of development and symptoms of aortic stenosis

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

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

It is characterized by the following symptoms:

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

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

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

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

Heart failure is pronounced. Symptoms appear:

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

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

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

Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Aortic stenosis is a disease that is defined as a heart defect. It is also called aortic stenosis. It is characterized by narrowing of the efferent vessel, that is, the aorta of the left ventricle, which is located near the aortic valve. This leads to the fact that the outflow of blood from the left ventricle is difficult, and the pressure difference between the left ventricle and the aorta increases sharply. What happens in the heart in this disease?

On the way of blood flow to the systole of the left ventricle, there is already a narrowed opening of the aortic valve, due to which the load on the left ventricle increases, which leads to its hypertrophy. If the narrowing is very sharp, not all blood is expelled into the aorta, a certain part of it remains in the left ventricle, which leads to its expansion. Due to the slow flow of blood into the aorta, arterial systolic pressure decreases. The contractility of the left ventricle decreases, resulting in stagnation of blood in the pulmonary circulation. This brings with it shortness of breath and attacks of cardiac asthma. It becomes clear that such a condition is a threat to human health and life. What are the causes of this heart disease?

Causes of the disease

Consider the most common causes leading to aortic stenosis.

1. Rheumatism. This is a complication of angina. Rheumatism is dangerous because the heart valves may appear cicatricial changes leading to narrowing of the aortic valve. Due to such cicatricial changes, the surface of the valves becomes rough, so calcium salts are easily deposited on it, which can independently cause stenosis of the aortic orifice.

1. Congenital defect. This means that the baby was already born with a defect in the aortic valve. This doesn't happen often, but it does happen. Congenital aortic valve disease can also present as a bicuspid aortic valve. In childhood, this may not carry with it any serious consequences, but at a more mature age it can lead to a narrowing of the valve or to its insufficiency.
2. Infective endocarditis.
3. atherosclerosis of the aorta.

Main symptoms

Symptoms of aortic stenosis largely depend on the degree of the disease, so in this section we will consider the classification of the disease. First, there are three degrees of severity of aortic valve stenosis.

1. Minor stenosis.
2. Moderate degree.
3. severe stenosis.

The degree is determined depending on how much the valve leaflets open, which occurs at the moment heart contraction. It also depends on the pressure difference after the valve and before it.

We single out five more stages, which will give important information, although this classification is not used very often.

1. Full compensation. At this stage, there are usually no complaints, but the defect itself can be identified by listening to the heart. Ultrasound shows a slight degree of stenosis. In this condition, it is only necessary to observe and correct the comorbidity without surgical intervention.
2. Latent heart failure. At this stage, there is increased fatigue, shortness of breath during physical exertion, and sometimes dizziness. ECG and fluoroscopy may reveal some changes. This stage may involve surgical correction of the defect.

1. Relative coronary insufficiency. There are cases when aortic stenosis is accompanied by angina pectoris, which usually occurs just at this stage. Shortness of breath increases, fainting and fainting are sometimes noted. A very important point in the treatment of aortic valve stenosis in the third stage is surgical treatment. If you miss the right moment in this regard, then further intervene surgically will be too late or ineffective.
2. Severe heart failure. The complaints of the patients are very similar to those described in relation to the previous stage, although at this stage they are more pronounced. For example, there is also shortness of breath, but it begins to be felt at rest. It is also possible the appearance of night attacks of suffocation. Surgical treatment is no longer possible, although there are cases when this option is still possible, but such cases are strictly individual.
3. Terminal stage. At this stage, heart failure progresses seriously. The patient's condition worsens greatly due to edematous syndrome and shortness of breath. Drug treatment does not help, improvement lasts only a short time, and surgical treatment cannot be used, since at this stage there is a high surgical mortality. In view of this, it becomes clear that it is impossible to bring the state of one's heart to the fifth stage.

It is necessary to recognize aortic valve stenosis in time, conduct an examination and begin to treat the disease.

Diagnostic methods

Aortic stenosis is diagnosed by several methods, but it must be borne in mind that there are no clinical manifestations long time. It is important for the patient to tell the doctor about chest pain, shortness of breath and other symptoms. The most frequent manifestations:

• angina attacks;
• syncope;
• symptoms of chronic insufficiency.

Sometimes the defect is found out after death, which occurred suddenly. Rarely, but there are bleeding in the gastrointestinal tract. There are several diagnostic methods that help identify aortic stenosis.

1. ECG. This examination reveals left ventricular hypertrophy. The presence of arrhythmias, and sometimes heart blockades, is also determined.
2. Phonocardiography. It registers such changes as a rough systolic murmur over the aorta and valve, as well as muffling of the first tones on the aorta.
3. radiographs. They are useful during the period of decompensation, since during this period the LV shadow expands, which manifests itself in the form of an elongated arc of the left cardiac contour. In the same period, aortic configuration of the heart and signs of pulmonary hypertension are observed.

1. Echocardiography. It reveals LV wall hypertrophy, thickening of the aortic valve flaps, and other changes that help identify aortic stenosis.
2. Probing of the cavities of the heart. It is performed in order to measure the pressure gradient, which helps to determine the degree of stenosis.
3. Ventriculography. Helps to identify concomitant mitral regurgitation.
4. Coronary angiography and aortography.

Treatment of the disease

The treatment of aortic stenosis has its limitations. This is especially true drug treatment. However, it must be used before aortic valve replacement, as well as before balloon valvuloplasty. This includes the use of the following groups of drugs:

• diuretics;
• cardiac glycosides.

In addition, during this period it is very important to treat atrioventricular blockade and atrial fibrillation. For surgical intervention, there are indicators that relate to aortic valve replacement in the case when aortic stenosis is diagnosed:

• asymptomatic aortic stenosis with severe course and normal function LV;
• severe degree of stenosis, which manifests itself clinically;
• stenosis in combination with LV dysfunction, we also include asymptomatic stenosis here.

Why is aortic valve replacement recommended? Because this method allows to improve the functional class and survival, as well as reduce the number of complications and symptoms.

Balloon valvuloplasty may also be performed. Its purpose is to relieve pressure or compression as the aortic orifice enlarges. Balloon dilatation is done on a working organ under fluoroscopy. A thin balloon is inserted into the valve opening. To expand the hole, this balloon is inflated at the end. Valvuloplasty is considered a less risky operation, although if it is performed on a patient at an advanced age, then the effect of it is temporary.

Possible consequences

In the beginning, we list the complications that aortic valve stenosis can bring with it:

• angina;
• fainting;
• progressive stenosis;
• infectious endocarditis;
• heart failure;
• hemolytic anemia.

It is expected that the average life expectancy in patients affected by aortic stenosis is five years after the onset of angina pectoris, three years due to the manifestations of syncope, and two years in combination with severe heart failure.

May happen sudden death. This occurs in twenty percent of cases and in those patients in whom the disease is accompanied by severe clinical manifestations.

Prevention

Preventive measures are aimed at preventing atherosclerosis, rheumatism and other risk factors. It is very important to constantly monitor the condition of your heart and go to the doctor in case of any deviations from the norm.

It cannot be argued that the disease we are discussing really threatens human life. Therefore, in order to prolong life, it is necessary to conduct healthy lifestyle life and regularly examined by a doctor.

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

General information

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

Classification of aortic stenosis

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

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

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

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

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

Hemodynamic disturbances in aortic stenosis

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

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

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

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

Symptoms of aortic stenosis

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

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

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

Diagnosis of aortic stenosis

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

Auscultatory signs of aortic stenosis are a rough systolic murmur over the aorta and over the mitral valve, muffled I and II tones on the aorta. These changes are also recorded during phonocardiography. According to the ECG, signs of left ventricular hypertrophy, 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 an elongation of the arc of the left contour of the heart, a characteristic aortic configuration of the heart, post-stenotic dilatation of the aorta, and signs of pulmonary hypertension. On echocardiography, thickening of the aortic valve flaps, limitation of the amplitude of movement of the valve leaflets in systole, hypertrophy of the walls of the left ventricle is determined.

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

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

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

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

Forecast and prevention of aortic stenosis

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

Main, prognostic significant symptoms serve as angina pectoris, fainting, left ventricular failure - in this case, the average life expectancy does not exceed 2-5 years. With timely surgical treatment aortic stenosis 5-year survival is about 85%, 10-year - about 70%.

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

Moderate aortic stenosis is a condition in which the opening in the valve of the same name narrows, which causes a violation of the outflow of blood from the left ventricle. This pathology is considered a heart disease and occurs in both adults and children. According to statistics, it most often develops in the elderly, mostly males. In aortic stenosis, the classification is extensive: by the nature of occurrence, by the severity of the course, by the degree and place of narrowing.

Types of disease and symptoms

Depending on where the narrowing formed, 3 forms of the disease are distinguished: subvalvular, supravalvular and valvular.

Subvalvular aortic stenosis, like valve stenosis, can be congenital or acquired. The supravalvular type of narrowing has only a congenital origin.

According to how narrowed the hole in the valve, 3 degrees of pathology are distinguished: minor, moderate and severe. Stenosis is considered insignificant if the opening area reaches sizes from 1.2 to 1.6 cm. With a moderate degree - 0.75 -1.2 cm. Severe (pronounced) aortic stenosis is characterized by narrowing of the valve to such a state that the opening area does not exceed 0.7 cm.

Normal condition and 3 degrees of aortic stenosis: minor, moderate and severe

As separate forms of this disease, 2 more of its types are distinguished - this is stenosis of the aortic mouth and subaortic.

The characteristics of the latter are as follows:

1. Has a hereditary origin. It is found exclusively in newborns.
2. Symptoms appear as the child grows.
3. Valve replacement surgery is performed in adolescence.
4. Perhaps medical maintenance of health in a satisfactory condition before surgical treatment.

Aortic stenosis is characterized by a more difficult diagnosis, since it is detected when the opening in the valve is narrowed by 30%. This defect develops against the background of other heart diseases and is observed more often in men.

The course of the disease and its symptoms

Aortic stenosis is one of those diseases that can go on for a long time without appearing in any way. The disease in its course goes through 5 stages:

With the timely start of treatment after the appearance of initial signs of pathology, the prognosis will be relatively good. Such concomitant diseases as severe hypotension or, as well as endocarditis, can aggravate the course of the disease.

In people with aortic stenosis, the symptoms of the disease are as follows:

• chest pain and tightness;
• disturbed hemodynamics;
• fast fatiguability;
• fainting;
• headaches and shortness of breath;
• arterial hypertension;
• violation of the heart rhythm.

With aortic stenosis, the properties of the pulse also change.

Reasons for the development of pathology

Before finding out the causes of aortic stenosis, it should be noted that the pathology can be congenital or acquired.

The congenital form accounts for about 10% of all cases of the disease and is the result of an anomaly in the development of the aortic valve and its various defects. It is considered normal when the valve has 3 flaps. They regulate the flow of blood from the left ventricle to the aorta. At congenital pathology this element will consist of two or one sash.

A two- or one-leaf valve differs from a normal one in a narrower lumen, which prevents the optimal outflow of blood. This causes overload of the left ventricle.

Normal tricuspid and abnormal bicuspid aortic valves

In the vast majority of cases, aortic stenosis is an acquired heart disease. This pathology in adults begins to occur after they reach 60 years of age. Experts identify a number of factors that increase the risk of developing aortic stenosis. These include smoking, high blood cholesterol, hypertension.

Acquired aortic valve stenosis develops as a result of the following reasons:

• disease of rheumatism;
• heredity;
• degenerative processes in the structure of the valve;
• systemic lupus erythematosus;
• severe renal failure;
• infectious endocarditis.

In patients with rheumatism, the valve leaflets are affected, which causes their contraction. As a result of this process, they become dense and lose their flexibility, which causes a narrowing of the hole in the valve. The deposition of salts on the aortic valve or often leads to the fact that the mobility of the leaflets decreases. This also results in contraction.

This kind of pathological transformation occurs in infective endocarditis. In some cases, degenerative processes observed in the valve itself lead to aortic stenosis. They begin to appear in people after 60 years. Since this reason is related to age-related changes and valve deterioration, the disease is called idiopathic aortic stenosis.

Degenerative processes that cause stenosis also occur with atherosclerosis of the aorta itself. In this case, sclerosis and impaired mobility of the valves occur. With aortic stenosis, an obstructive process in the heart is observed - difficulty in the movement of blood flow into the aorta from the left ventricle.

How does pathology develop in children?

In newborns and preschool children, this pathology may occur without symptoms, but as they grow, stenosis will begin to appear. There is an increase in the size of the heart and, accordingly, the volume of circulating blood, and the narrow lumen in the aortic valve remains unchanged.

Narrowing of the aortic valve in newborns occurs due to abnormal development of the valves during fetal development. They grow together or do not separate into 3 separate valves. You can see such a pathology in the fetus as early as 6 months of pregnancy using echocardiography.

Such a diagnosis is mandatory and very important, since immediately after birth the child develops critical stenosis. The danger of the condition is that the left ventricle with aortic stenosis works with an excessively increased load. But he will not be able to function in this mode for a long time. Therefore, if such a pathology is detected in time, it is possible to perform an operation after the birth of a child and prevent an unfavorable outcome.

Critical stenosis occurs when the lumen in the aortic valve is less than 0.5 cm. Non-critical stenosis causes a deterioration in the child's condition during the first year of his life, but for several months after birth, the baby may feel quite satisfactory. There will be poor weight gain and tachycardia with shortness of breath. In any case, if the parents suspected signs of illness in the child, it is necessary to consult a pediatrician.

You can guess about the stenosis of the mouth of the aorta of a newborn by the following signs:

• a sharp deterioration in the condition of the child in the first 3 days after birth;
• the baby becomes lethargic;
• no appetite, bad breastfeeding;
• the skin becomes bluish.

In older children, the situation is not as scary as in newborns. Signs of a defect may not appear for a long time, and it is possible to trace the development of the pathology in dynamics by choosing the appropriate method of correction. It is impossible to ignore the obvious signs of the disease, it must be treated, since it can be fatal. There are 3 options for the development of pathology, as a result of which the methods for its elimination are different:

• the valve leaflets stuck together and their separation is necessary;
• valve flaps have been changed so much that a complete replacement is required;
• the diameter of the valve opening is so small that it is not able to pass through itself a device for replacing a part of an organ.

Diagnosis and conservative treatment

The main method by which aortic valve stenosis is detected is considered ultrasound procedure hearts. If ultrasound is performed in combination with Doppler, then it is possible to evaluate the blood flow velocity. Traditional ECG reveals only some of the accompanying signs of this pathology, characteristic of its later stages. Auscultation is also used, it will allow you to determine a coarse murmur in the heart with aortic stenosis. However, listening alone cannot be the basis for a definitive diagnosis. It indicates only a possible pathology.

ECG of a patient with aortic stenosis. Hypertrophy of the left atrium. Hypertrophy and systolic overload of the left ventricle

A minor ailment in the absence of complaints from the patient does not require therapeutic measures. Treatment of aortic stenosis becomes necessary with the increase of threatening symptoms, which indicate the progression of the disease, which is life-threatening. To slow down this process in the absence of the possibility of surgical intervention, the patient is prescribed medication.

Your doctor may recommend diuretics to reduce your risk of heart failure. In addition, as part of drug therapy, antiarrhythmic drugs and medications are prescribed to normalize blood pressure. One of the directions conservative therapy is the elimination or prevention of atherosclerosis.

Drug therapy is prescribed to those patients who, due to objective reasons, are not subject to surgical treatment or it is not yet shown to them due to the slow course of the disease without severe symptoms. Medications to eliminate aortic stenosis are selected individually, taking into account the causes that caused this disease.

Conservative treatment of stenosis is also indicated for those patients who have already undergone valve replacement surgery. This does not apply to all operated patients, but only to those in whom this manipulation was caused by rheumatism. In relation to them, the main therapeutic goal is the prevention of endocarditis.

This is inflammatory disease membranes of the heart and valves. Since it has an infectious nature of development, antibacterial drugs are used to treat it. Suitable means and the duration of their use is determined by the attending physician. You need to be prepared for the fact that therapy can be both long-term and lifelong.

Surgery

The main treatment for severe aortic stenosis is to replace the damaged valve with surgery. For this, the following surgical techniques are used:

• open operation;
• balloon valvuloplasty;
• percutaneous valve replacement.

Aortic valve replacement

Open surgery involves opening the chest and artificial. Despite the complexity and trauma, this intervention is a highly effective way to replace the aortic valve. As a replacement, artificial, made of metal, and donor, borrowed from animals, valves are used. In the case of a metal prosthesis, the patient must take anticoagulants, blood thinners, for the rest of his life. This is due to the fact that as a result of the operation, the risk of thrombosis increases. The donor prosthesis is sewn in temporarily, its service life is not more than 5 years. After the expiration of this period, it needs to be replaced.

Balloon valvuloplasty is used to treat children. This technique is not suitable for adult patients, since the valve leaflets become more fragile with age and can be destroyed as a result of intervention. For this reason, it is carried out in relation to men and women in exceptional cases. One of them is the inability to use general anesthesia.

Aortic balloon valvuloplasty

The operation is performed as follows: a special balloon is inserted through the femoral artery, which expands the narrowed lumen of the aorta. All manipulations are performed under X-ray control. Observation of patients who have undergone a similar procedure shows that re-narrowing of the valve occurs. In addition, in rare exceptions, such treatment can cause complications - these are:

• valve insufficiency;
• embolism of cerebral vessels;
• stroke.

Percutaneous valve replacement is performed on the same principle as balloon valvuloplasty. The only difference is that in this case an artificial valve is installed, which opens after its introduction through the artery. It is tightly pressed against the walls of the vessel and begins to perform its functions. Although this method of aortic valve replacement is minimally traumatic, it has many contraindications. Therefore, it is far from suitable for all patients with such a pathology as aortic stenosis.