Aortic valve stenosis with regurgitation
Introduction
Aortic valve stenosis combined with insufficiency The normal aortic valve area exceeded 3.0 cm2, and the stenosis was mild when the valve area was reduced to 1.5 cm2; the moderate stenosis was 1.0 cm2; and the severe stenosis was <1.0 cm2. Aortic stenosis can be caused by sequelae of rheumatic fever, congenital stenosis or senile aortic valve calcification. 80% of patients with aortic stenosis are male, and simple rheumatic aortic stenosis is rare, often associated with aortic regurgitation. And mitral valve disease combined, pathological changes are adhesion and fibrosis at the valve junction, the deformation of the valve aggravates the damage of the valve, leading to calcium deposition and further stenosis. basic knowledge The proportion of illness: 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: congestive heart failure, cerebral embolism, infective endocarditis
Cause
Aortic valve stenosis combined with the cause of dysfunction
Disease factors (75%):
Aortic stenosis can be caused by sequelae of rheumatic fever, congenital stenosis or senile aortic valve calcification. 80% of patients with aortic stenosis are male, and simple rheumatic aortic stenosis is rare, often with the main Arterial regurgitation and mitral valve disease are present. The pathological changes are adhesion and fibrosis at the valve junction. The deformation of the valve aggravates the damage of the valve, leading to calcium deposition and further stenosis.
Congenital factors (15%):
Congenital aortic stenosis can be single-leaf, two-leaf or three-leaf. The single-leaf type is already stenotic at birth, and the posterior fibrosis and calcification are progressively aggravated, causing severe left ventricular outflow obstruction. More than one year of death, 50% of congenital aortic stenosis is bilobal, 30% is trifoliate. These two kinds of leaflet malformations can be no obvious stenosis in childhood, but abnormal valve leaflets The structure is degenerative due to eddy current impact, causing thickening, calcification, and stiffness of the valve leaflets, eventually leading to stenosis of the valve stenosis, and may be combined with regurgitation. Aortic root eddy current impact may occur after stenosis (see "Congenital Cardiovascular Disease" chapter "Aortic stenosis" section).
Body aging (10%):
Calcification of senile aortic valve is a degenerative change, accounting for 18% of elderly patients, degenerative valve changes, fibrosis and calcification, leaflet fusion, relatively narrow stenosis, and some patients may be associated with insufficiency .
The main pathophysiological changes after aortic stenosis are increased left ventricular resistance during systole, which increases left ventricular contractility to increase transvalvular pressure gradient, maintain normal cardiac output at rest, and thus gradually cause left ventricular hypertrophy. The left ventricular diastolic compliance decreased, and the end-diastolic pressure increased. Although the resting cardiac output was normal, the cardiac output was insufficient during exercise. After the severe stenosis, the transvalvular pressure gradient decreased. Atrial pressure, pulmonary artery pressure, pulmonary capillary compression and right ventricular pressure can be increased, cardiac output is reduced, cardiac output can reduce myocardial oxygen supply, hypotension and arrhythmia, cerebral insufficiency can cause head Fainting, syncope and other manifestations of cerebral hypoxia, left ventricular hypertrophy, increased contractility, significantly increased myocardial oxygen consumption, further aggravating myocardial ischemia.
Prevention
Aortic stenosis with insufficiency prevention
Properly avoid excessive physical labor and strenuous exercise, prevent infective endocarditis, regular follow-up and review echocardiography.
Complication
Aortic stenosis with complications of insufficiency Complications Congestive heart failure, cerebral embolism, infective endocarditis
(1) 50% to 70% of patients with congestive heart failure die of congestive heart failure.
(B) embolism is more common in calcified aortic stenosis, the most common cerebral embolism, can also occur in the retina, limbs, intestines, kidneys and spleen and other organs.
(C) subacute infective endocarditis can be seen in the two-leaf aortic stenosis.
Symptom
Aortic valve stenosis combined with insufficiency symptoms Common symptoms Oval hole closed incomplete labor syncope Paroxysmal nocturnal dyspnea purulent heart valve disease dyspnea systolic murmur fossa ovalis fossa fatigue systolic tremor
(a) symptoms
Due to the large compensatory capacity of the left ventricle, even if there is a significant aortic stenosis, the patient may have no obvious symptoms for a long time, and the clinical symptoms will not occur until the valve area is less than 1 cm2.
Labor force breathing difficulties
This is due to decreased left ventricular compliance and left ventricular enlargement, left ventricular end-diastolic pressure and left atrial pressure, resulting in increased pulmonary capillary pressure and pulmonary hypertension. As the disease progresses, daily activities can cause difficulty breathing. And sitting breathing, when tired, emotional, respiratory infections and other incentives, can induce acute pulmonary edema.
2. Angina
One-third of patients may have exertional angina pectoris. The mechanism may be: hypertrophic myocardial contraction, increased left ventricular pressure and systolic wall tension, prolonged ejection time, resulting in increased myocardial oxygen consumption; increased myocardial contraction Indoor pressure squeezes the small branch of the coronary artery in the wall of the chamber, causing a decrease in coronary flow; diastolic compliance in the left ventricle is decreased, end-diastolic pressure is increased, coronary perfusion resistance is increased, coronary perfusion is reduced, and endocardial myocardium is reduced. Ischemia is particularly severe; the valve is severely stenotic, the cardiac output is decreased, the mean arterial pressure is reduced, and the coronary blood flow is reduced. The angina pectoris occurs during nighttime sleep and after labor. Cough is mostly dry cough; bronchitis is complicated. Or when the lung is infected, cough mucus or purulent sputum, the left atrium significantly enlarges the compression of the bronchus can also cause cough.
3. Labor syncope
The lighter is black Mongolian, which may be the first symptom. It may occur in physical activity or immediately after the physical activity. The mechanism may be: the peripheral vascular resistance decreases while the heart discharge does not increase correspondingly; the blood volume decreases after the exercise stops, left Ventricular filling and cardiac output decreased; exercise increased myocardial ischemia, resulting in a sudden decrease in myocardial contractility, causing a decrease in cardiac output; various arrhythmias may occur during exercise, resulting in a sudden decrease in cardiac output, above A sudden decrease in the amount of blood output from the heart causes a significant deficiency in blood supply to the brain, which can cause syncope.
4. Gastrointestinal bleeding
Found in severe aortic stenosis, the cause is unknown, some may be due to vascular dysplasia, vascular malformation, more common in the elderly aortic valve calcification.
5. Thromboembolism
More common in elderly patients with calcified aortic stenosis, embolism can occur in the cerebral vessels, retinal artery, coronary artery and renal artery.
6. Other symptoms
In the advanced stage of aortic stenosis, there may be various manifestations of decreased cardiac output: obvious fatigue, weakness, peripheral purpura, and left heart failure: squat breathing, paroxysmal nocturnal dyspnea, and pulmonary edema. Right heart failure after severe pulmonary hypertension: autologous venous hypertension, enlarged liver, atrial fibrillation, tricuspid regurgitation, etc.
(two) signs
Cardiac auscultation
The second intercostal space on the right edge of the sternum can hear rough, loud jet systolic murmur, which is a diamond that increases first and then decreases. After the first heart sound, the middle of the contraction reaches the loudest, then gradually weakens, and the aortic valve closes. (second sound) before termination; often accompanied by systolic tremor, after inhalation of isoamyl nitrite, the murmur can be enhanced, the murmur is transmitted to the carotid artery and the subclavian artery, and sometimes to the lower sternal or apical region, usually the longer the noise, The louder the sound, the more the peak of the contraction appears, the more severe the aortic valve stenosis, but when the heart failure is combined, the blood flow velocity through the valve orifice is slowed down, the noise becomes light and short, and the early jet sound can be heard and contracted, especially in congenital Non-calcified aortic stenosis is more common. After the valve is calcified and stiff, the sound disappears. When the valve activity is limited or the calcification is obvious, the second heart sound of the aortic valve is weakened or disappeared. The second heart sound can also be reversely split, often at the apex. The district sound and the fourth heart sound suggest that the left ventricular hypertrophy and end-diastolic pressure increase, and the third heart sound (diastolic galloping) can be heard when the left ventricle is enlarged and exhausted.
2. Other signs
The pulse is flat and weak. When the blood is severely stenotic, the blood volume is reduced, the systolic blood pressure is reduced, and the pulse pressure is reduced. The elderly patients often have aortic atherosclerosis, so the systolic blood pressure is not significantly reduced, and the heart dullness is normal. Expanding to the left, the apical region can reach the systolic lift-like pulsation, and the left lateral position can be double-pulsed, the first is the atrial contraction to increase the left ventricular filling, the second is the ventricular contraction, continuous and powerful, the bottom of the heart, Constriction tremor can be reached in the supraclavicular and carotid arteries.
Examine
Aortic valve stenosis combined with insufficiency examination
(1) X-ray examination
Left heart margin is round, heart shadow is not big, common aortic stenosis and aortic calcification, when there is no calcification in adult aortic valve, there is generally no severe aortic stenosis, left ventricle is obviously enlarged in heart failure, also visible The left atrium is enlarged, the main pulmonary artery is prominent, the pulmonary vein is widened, and the signs of pulmonary blood stasis.
(two) ECG examination
The electrocardiogram of patients with mild aortic stenosis can be normal, the left ventricular hypertrophy and strain of ECG in severe cases, the increase of ST segment depression and T wave inversion suggest that ventricular hypertrophy is progressing, the left atrial enlargement is more common, and the aortic valve calcification is severe. , visible left anterior branch block and other various degrees of atrioventricular or bundle branch block.
(three) echocardiography
M-mode ultrasound showed thickening of the aortic valve, the range of motion was reduced, the opening amplitude was less than 18mm, and the enhancement of the leaflet reflected light point prompted valvular calcification, aortic root dilatation, left ventricular posterior wall and ventricular septal symmetry hypertrophy, two-dimensional echocardiography It can be seen that the aortic valve systolic phase is a centripetal curvature, and the congenital valve malformation can be confirmed. Doppler ultrasound shows a slow and decreasing blood flow through the aortic valve, and the maximum transvalvular pressure gradient can be calculated.
(four) left heart catheterization
The pressure of the left atrium, left ventricle and aorta can be directly measured, the left ventricular systolic blood pressure is increased, and the aortic systolic blood pressure is decreased. As the aortic valve stenosis worsens, the pressure gradient increases, and the left atrial contraction pressure curve is high. The a wave should be considered in the following cases: young patients with congenital aortic stenosis, although asymptomatic but need to understand the degree of left ventricular outflow obstruction; suspected left ventricular outflow obstruction rather than valve cause; want to distinguish Whether aortic stenosis is associated with coronary artery disease, coronary angiography should be performed at the same time; multivalvular disease before surgery.
Diagnosis
Diagnosis and diagnosis of aortic stenosis complicated with regurgitation
The atrial aortic valve stenosis is found in the aortic valve area of the heart, and the aortic valve stenosis can be diagnosed. Echocardiography can confirm the diagnosis. The clinical aortic stenosis should be differentiated from the systolic murmur of the aortic valve area in the following cases:
(1) Hypertrophic obstructive cardiomyopathy is also known as idiopathic hypertrophic aortic subvalvular stenosis (IHSS). The fourth intercostal space of the left sternal border can be audible and systolic murmur. The systolic snoring is rare. The aortic area is the first. The second heart sound is normal. The echocardiogram shows asymmetry hypertrophy of the left ventricular wall, the ventricular septum is thickened, and the ratio of the left ventricle posterior wall is 1.3. The systolic ventricular septum is moved forward and the left ventricular outflow tract is narrowed. The anterior leaflet of the cusp is displaced to the mitral regurgitation.
(2) Aortic dilatation is seen in various causes such as hypertension, aortic dilatation caused by syphilis, and a short systolic murmur can be heard in the second intercostal space on the right sternal border. The second heart sound in the aortic region is normal or hyperthyroidism. The second heart sound splits, and echocardiography can confirm the diagnosis.
(3) Pulmonary stenosis may be located in the second rib of the left sternal border and the rough systolic murmur, often accompanied by systolic click, the second heart sound of the pulmonary valve area is weakened and split, and the second heart sound of the aortic valve area is normal. The right ventricular hypertrophy is enlarged, and the trunk of the pulmonary artery is narrowed and expanded.
(4) Tricuspid regurgitation The lower left rim of the sternum and the high-grade full systolic murmur. When the inhalation increases, the blood volume increases, the noise can be enhanced, the exhalation is weakened, the jugular vein beats, the liver enlarges, the right atrium and the right The ventricle is significantly enlarged and echocardiography confirms the diagnosis.
(5) mitral regurgitation in the apical region, systolic murmur, squeaky to the left sinus; after inhalation of isoamyl nitrite, the murmur is weakened, the first heart sound is weakened, the second heart sound of the aortic valve is normal, and the aortic valve No calcification.
