Aortic valve insufficiency
Introduction
Introduction to aortic regurgitation Aortic insufficiency (aorticinsufficlency) may be more common in male patients due to aortic valve and annulus, as well as lesions of the ascending aorta, accounting for about 75%; female patients are often accompanied by mitral valve disease. Among the chronically ill, the most common cause of leaflet damage caused by rheumatic fever is two-thirds of all patients with aortic regurgitation. basic knowledge The proportion of illness: 0.005%-0.007% Susceptible people: no specific population Mode of infection: non-infectious Complications: acute myocardial infarction congestive heart failure acute pulmonary edema
Cause
Aortic valve regurgitation
Rheumatic heart disease (30%):
About 2/3 of aortic incompetence is caused by rheumatic heart disease. Due to fibrosis, thickening and shortening of the leaflets, the edge of the diastolic valve leaflets is affected. Simple aortic regurgitation is rare in rheumatic heart disease, often due to fusion of the valve junction with varying degrees of stenosis, often combined with mitral valve damage.
Infective endocarditis (20%):
Infectious neoplasms cause the leaflets to be damaged or perforated, and the leaflets are prolapsed due to impaired support structure or the mites are blocked between the leaflets to cause closure. Even if the infection has been controlled, leaflet fibrosis and contracture can continue. Depending on how fast the damage progresses, it can be manifested as acute, subacute or chronic insufficiency, which is a common cause of simple aortic regurgitation.
Congenital malformation (15%):
1 Two-leaf aortic valve accounts for 1/4 of clinical simple aortic regurgitation. Due to a gap in the edge of one leaf or a large and long leaf that is prolapsed into the left ventricle, there is a dysfunction in childhood; adulthood is mostly due to progressive leaflet fibrosis contracture or secondary to infective endocarditis. Not complete. In the case of 2-ventricular septal defect, aortic valve insufficiency can be caused by loss of support without coronary valve, accounting for about 15% of ventricular septal defect.
Aortic valve mucoidosis (10%):
The leaflets are prolapsed into the left ventricle during diastole. Occasionally combined with cystic necrosis in the aortic root, may be a congenital cause.
Ankylosing spondylitis (5%):
The base and distal edges of the leaflets are thickened with shortening of the leaflets.
Prevention
Aortic regurgitation prevention
For aortic regurgitation with asymptomatic and normal left ventricular function, it should be checked every six months or when symptoms appear, limiting physical activity, avoiding the use of drugs that inhibit myocardium, such as propranolol. If angina is not treated, no surgical treatment is often used. Can be dying, so should strive for timely surgery, can not wait and see, such as acute onset, because the left ventricular tolerance is very limited, once the appearance of left heart failure, the prognosis is extremely dangerous, should be operated early, even when the heart is significantly enlarged Without symptoms, digitalis drugs and other cardiac-lowering drugs should be given as soon as possible. Because the patients are very resistant to atrial fibrillation and slow arrhythmia, they should be actively prevented and treated. Prone to concurrent infective endocarditis, preventive measures should be taken.
Complication
Aortic regurgitation complications Complications Acute myocardial infarction Congestive heart failure Acute pulmonary edema
Aortic valve regurgitation is often complicated by acute myocardial infarction. The possible mechanisms are:
1, left ventricular dilatation, cardiac insufficiency and increased myocardial weight caused by increased myocardial oxygen consumption and decreased coronary blood flow.
2, ventricular diastolic aortic regurgitation caused by increased left ventricular end-diastolic pressure and diastolic coronary perfusion pressure, leading to myocardial ischemia and necrosis.
3. The coronary blood flow reserve capacity is reduced.
4, aortic root aneurysm compression coronary artery caused by reduced or interrupted blood flow, the disease can be complicated by congestive heart failure, and more common, and the main cause of death of aortic valve insufficiency, once the occurrence of cardiac insufficiency Symptoms often die within 2 to 3 years, infective endocarditis is also visible, and embolism is rare.
Symptom
Aortic valve regurgitation Symptoms Symptoms Sitting breathing, exertional dyspnea, dyspnea, fatigue, femoral artery, gunshot, unstable angina, dizziness, palpitations, syncope, jugular vein engorgement
(a) symptoms
Usually, patients with aortic regurgitation are asymptomatic for a long period of time. Even if the aortic regurgitation is obvious, the symptoms can be as long as 10 to 15 years. Once heart failure occurs, it progresses rapidly.
1, palpitations: heart pulsation discomfort may be the earliest complaint, due to the obvious increase in the left ventricle, increased apex beats, especially in the left lateral or prone position, emotional or physical activity caused by tachycardia, Or ventricular premature beats can make the palpitations more obvious. Because the pulse pressure is significantly increased, it is often felt that the body has strong arterial pulsation, especially in the head and neck.
2, breathing difficulties: labor dyspnea first appeared, indicating that the heart reserve capacity has been reduced, as the disease progresses, there may be sitting breathing and nighttime paroxysmal breathing difficulties.
3, chest pain: angina is less common than aortic stenosis, chest pain may be caused by left ventricular ejection caused by excessive stretching of the ascending aorta or a significant increase in the heart, there are also factors of myocardial ischemia, angina can be active Occasionally, and at rest, lasting longer, poor response to nitroglycerin; nighttime angina pectoris may be due to a decrease in diastolic blood pressure due to slow heart rate during rest, which reduces coronary blood flow; Those who complained of abdominal pain may be suspected to be related to visceral ischemia.
4, syncope: When changing body position quickly, dizziness or dizziness may occur, and syncope is less common.
5, other symptoms: fatigue, active endurance decreased significantly, excessive sweating, especially in the presence of nocturnal paroxysmal dyspnea or nighttime angina pectoris, hemoptysis and embolism is less common, liver congestion can occur in advanced right heart failure , tenderness, edema of the ankle, pleural effusion or ascites.
6, acute aortic regurgitation, due to sudden increase in left ventricular volume load, increased wall tension, left ventricular dilatation, acute left heart failure or pulmonary edema can occur.
(two) signs
1. Cardiac auscultation: a diastolic murmur in the aortic valve area, which is a high-profile descending type of qi-like murmur. The anterior anteversion of the sitting position is obvious. The most loud area depends on whether there is significant ascending aortic dilatation; rheumatoid aorta Lighter expansion, the loudest in the third intercostal space on the left sternal border, can be transmitted down the sternal border to the apical region; due to Marfan syndrome or syphilitic heart, due to the high expansion of the ascending aorta or aortic annulus Therefore, the murmur is most loud in the second intercostal space on the right edge of the sternum. Generally, the more severe the aortic valve is incomplete, the longer the murmur is, the louder the loudness is, and the mildly closed is not complete. This murmur is soft and only occurs in early diastole. It can only be heard before the patient takes a seat and can be heard at the end of the breath; when the heavier closure is closed, the murmur can be full diastolic and rough; in severe or acute aortic regurgitation, the left ventricular end-diastolic pressure is increased to Equal to the aortic diastolic pressure, so the duration of the noise is shortened, such as the nature of the vocal music, often suggesting that a part of the valve is flipped, torn or perforated, and the aortic dissection sometimes also has musical tones, which may be Aorta proximal end diastolic prolapse or aortic lumen so that the middle of the flow of blood to the ventricle through the aortic valve.
When the aortic valve regurgitation is obvious, the mid-systolic jetting is often heard in the aortic valve area at the base of the heart. The softer, shorter high-pitched murmur is transmitted to the neck and sternum, which is a great stroke volume. The aortic valve is not caused by the stenosis of the aortic valve. The apex area often smells a soft, low-key rumbling-like diastolic or pre-systolic murmur, which is the Austin-Flint murmur. This is due to the aorta. The valvular regurgitation of the anterior lobes of the mitral valve interferes with the anterior mitral regurgitation, causing relative mitral stenosis. At the same time, the aortic regurgitation and the left atrial return blood are impacted and mixed, resulting in eddy currents. The murmur is enhanced when the palm is firmly gripped. When the inhalation of isoamyl nitrite is weakened, when the left ventricle is significantly enlarged, the functional mitral regurgitation is caused by the extrapneumatic shift of the papillary muscle, and the systolic and systolic murmur can be heard in the apical region. , conduction to the left and left.
When the valve activity is poor or the reflux is severe, the second heart sound of the aortic valve is weakened or disappeared; the third heart sound is often heard, suggesting left heart dysfunction; the left atrial compensatory contraction is enhanced and the fourth heart sound is heard due to the systolic period. A large increase in stroke volume, a sudden expansion of the aorta, can cause a loud contraction early jet sound.
In acute severe aortic regurgitation, the diastolic murmur is soft and short; the first heart sound is weakened or disappeared, and the third heart sound can be heard; the pulse pressure can be close to normal.
2, other signs: pale face, apex beat to the left and down, a wide range, and visible strong lifting pulsation, the heart sounds the sound to the left to expand, the aortic valve area can touch the systolic tremor, and to the neck Conduction; the left lower edge of the sternum can reach diastolic tremor, the carotid pulsation is obviously enhanced, and it has double pulsation, the systolic blood pressure is normal or slightly higher, the diastolic blood pressure is significantly reduced, the pulse pressure difference is obviously increased, and the peripheral vascular signs can appear: water flushing Corrigans pulse, Quinckes sign, Traubes sign, Duroziezs sign of the femoral artery and diastole, and the up and down swing of the head with the heart rate (de- Mussets sign), pulmonary hypertension and right heart failure, visible jugular vein engorgement, enlarged liver, lower extremity edema.
Examine
Aortic regurgitation
1, X-ray inspection:
The left ventricle is obviously enlarged, and the ascending aorta and aortic node are dilated. It is an aortic heart. The aortic pulsation is obviously enhanced under fluoroscopy. It is a "rocking chair" swing with the left ventricular pulsation, and the left atrium can be enlarged. In high pressure or right heart failure, the right ventricle is enlarged, pulmonary venous congestion, pulmonary interstitial edema, calcification of the aortic valve leaf and ascending aorta are often seen, and aortic root angiography can estimate the degree of aortic regurgitation, such as angiography. The density of the agent returning to the left ventricle is more pronounced than that of the main aorta, indicating severe insufficiency; if the contrast agent reflux is limited to the subvalvular or linear reflux, it is mild reflux.
2, ECG check:
Mild aortic insufficiency can be normal ECG, severe left ventricular hypertrophy and strain, left axis deviation, I, aVL, V5 ~ 6 lead Q wave deepening, ST segment depression and T wave inversion; late left Atrial enlargement can also be seen in bundle branch block.
3. Echocardiography:
The left ventricular cavity and its outflow tract and ascending aorta roots have an enlarged inner diameter. When the myocardial contractile function is compensated, the left ventricular posterior wall systolic movement increases. The wall motion velocity and amplitude are normal or increased, and the diastolic mitral anterior leaflet Rapid high-frequency vibration is a characteristic feature of aortic valve insufficiency. Aortic valve thickening can be seen on two-dimensional echocardiography, diastolic closure is poorly matched; Doppler ultrasound shows diastolic eddy current under aortic valve, The detection of aortic regurgitation is very sensitive and can determine its severity. Echocardiography is also valuable for the evaluation of left ventricular function in patients with aortic regurgitation. It also contributes to the judgment of the cause and can show the two-leaf master. Arterial valve, valve prolapse, rupture, or neoplasm formation, ascending aortic dissection.
4. Radionuclide inspection:
Radionuclide blood pool imaging, showing left ventricular enlargement, increased end-diastolic volume, left atrium can also be expanded, can determine left ventricular systolic function, for a certain value for follow-up.
Diagnosis
Diagnosis and diagnosis of aortic regurgitation
diagnosis
Can be diagnosed based on clinical performance and laboratory tests.
Differential diagnosis
Aortic regurgitation should be identified with the following diseases:
1. Pulmonary valve insufficiency: This disease is often caused by pulmonary hypertension. At this time, the carotid artery beats normally, the second heart sound in the pulmonary valve area is hyperthyroidism, and the diastolic murmur of the left sternal border is enhanced when inhaling, and there is no change when the fist is hard. The electrocardiogram is Right atrium and right ventricle hypertrophy, X-ray examination of the main trunk of the pulmonary artery, more common in mitral stenosis, can also be seen in the atrial septal defect.
2, aortic sinus rupture: the disease often breaks into the right heart, there is persistent murmur in the lower left sternal border, but sometimes the murmur is similar to the aortic regurgitation and systolic murmur, but there is a sudden Chronic chest pain, progressive right heart failure, aortic angiography and echocardiography can confirm the diagnosis.
3, coronary arteriovenous fistula: more cause continuous murmur, but can also hear diastolic murmur in the aortic valve area, or its murmur diastolic composition is louder, but the electrocardiogram and X-ray examination is more normal, aortic angiography can be seen There is traffic between the aorta and the coronary sinus, the right atrium, the ventricular or pulmonary trunk.
