The aortic valve of the heart is the maximum speed. The structure of the aortic valve of the heart and why do AK defects occur? What diseases can be detected

06.06.2020

It is a safe procedure that can be used for both children and adults.

Ultrasound of the heart: the purpose of the study

Ultrasound of the heart - effective diagnostics of the work and structure of the heart

A study using ultrasound is prescribed in the following cases:

Indications for an ultrasound scan are also the rehabilitation period after heart surgery or a heart attack. If there are jumps in blood pressure, dizziness, edema, weakness, then ultrasound is also performed. It is prescribed for thrombophlebitis and varicose veins.

Ultrasound can be prescribed for infants with signs of a congenital defect: poor weight gain, cyanosis skin, heart murmurs, etc.

Ultrasound of the heart helps to determine the norm and deviations in the work of this organ, to assess the size, frequency of beats, the speed of intracardiac blood flow and other indicators. During the examination, you can assess the condition and identify deviations of large vessels, myocardium, mitral valve, etc. An echocardiogram is done in conjunction with Doppler sonography to assess blood flow.

This study is absolutely safe and can be performed at any age. There are no contraindications to ultrasound, but the large breast size in women, deformation chest, attacks of bronchial asthma.

Preparation for the procedure and ultrasound

Ultrasound examination of the heart

No special preparation is required for an ultrasound scan. Unlike ultrasound examination of other organs, where preparation includes adherence to a certain diet and drinking regimen, these rules do not need to be adhered to before conducting an ultrasound of the heart.

The day before the study, you should stop taking alcoholic and energy drinks, as there may be a distortion of the heart rhythm. Do not smoke before testing. Nicotine slows down the heartbeat, which can cause erroneous results.

A few hours before the ultrasound, you should not take Validol, Corvalol, Cormentol, etc.

Please be aware that results may not be accurate. It depends on many factors: physical activity before the study, anatomical features, doctor's experience, etc.

The procedure is carried out as follows:

The doctor asks you to lie on your back or, if necessary, on your side.
Next, a special gel is applied to the chest.
The doctor passes the probe along the chest, examining any part of the heart muscle.

If necessary, a transesophageal ultrasound is performed. This is a more informative method that allows you to assess the work and condition of the heart from any angle. This type of echocardiography is used if there are any obstacles to the passage of the ultrasound wave: a thick layer of subcutaneous adipose tissue, etc. The duration of the study does not exceed 15 minutes. After the end of the study, the patient is given the results of the study and the alleged diagnosis.

Decoding: normal indicators

Normal readings will vary depending on the age of the patient. This is also influenced by existing chronic diseases.

Normal ultrasound readings:

Normally, in a healthy person, the diameter of the aorta is 2-3.8 cm, the size of the pulmonary artery does not exceed 3.1 cm, and the diameter of the mouth is within 1.7-2.4 cm.
The size of the aortic valve (AC) is 1.5-2.6 cm, the size of the left atrium (LV) is 1.9-4.0 cm, and the size of the right atrium (RP) is 2.7-4.5 cm.
When the heart muscle relaxes, the volumes of the ventricles change. For the right, the normal indicator is 1-2.6 cm, and for the left - 3.5-5.8 cm.The end-systolic volume of the left ventricle is normally 3.1-4.3 cm.
The ejection fraction should not exceed 60% and be at least 55%.
When examining the mitral and bicuspid valve, the blood flow rate should normally be 0.6-1.3 m / s. The speed of transuspid blood flow is within 0.3-0.7 m / s, transpulmonary - 0.6-0.9 m / s, and in the terminal section of the left ventricle - 0.7-1.1 m / s.
In women and men, the mass of the myocardium is significantly different and is 95 g and 135 g, respectively.
For one reduction, the amount of blood that is ejected by the left ventricle is ml.
The leaflets of the mitral valve should have a flat surface; when the heart muscle contracts during systole, their deflection in the left atrium is normally no more than 2 mm.
The leaflets of the aortic valve should be the same, fully open in systole and close in diastole.

Interpretation of results should only be done by a qualified physician.

Possible heart disease on ultrasound

Changing the parameters of the heart is a sign of organ pathology

If the parameters differ significantly from normal values, then this may indicate the presence of cardiac pathology:

With an increase in the thickness of the walls of blood vessels, cardiomyopathy is diagnosed, in which a pathological change in the myocardium is observed. Thinning of the heart walls or aneurysm occurs most often with hypertension.
If there is a change in the size of the vessels, then this is one of the signs of cardiac pathology.
If the blood flow rate is reduced, then this indicates a valve defect.
With a low volume of blood ejected by the heart with each contraction, heart failure or blood stasis is detected.

Ultrasound of the heart allows you to identify the following diseases and heart defects vascular system:

Congenital and acquired defects (defect of the interventricular and interatrial septa, patent ductus arteriosus, stenosis of the mitral and aortic valves)
Ischemic disease
Violation of the rhythm of the heart
Heart failure
Pericarditis
Endocarditis
Pulmonary hypertension

Changes in the structure of the valve leaflets, their narrowing or expansion, as well as multidirectional movement indicate heart defects. They can diagnose stenosis, valve failure and other pathologies. Cardiac changes are observed in elderly people suffering from obesity and alcoholism, as well as athletes, smokers.

Ultrasound of the heart during pregnancy

Ultrasound of the heart during pregnancy is prescribed in case of clinical indications of a possible pathology

The study is prescribed for pregnant women, since it is during this period that the load on all organs of a woman is significantly increased. It is important to monitor the condition of the woman and the fetus. This is an optional study and is only done if a doctor tells you to.

Prescription of ultrasound examination during pregnancy:

enlarged liver
the appearance of fatigue, shortness of breath
chronic vascular disease
slowdown and increased heart rate
pain in the region of the heart
previous heart surgery
blood clots in blood vessels

If a woman in a position periodically loses consciousness, her skin turns blue and her hands are cold, then this is a reason to consult a doctor for examination. It is also important to have your heart checked if the pregnant woman is not gaining weight. It should be remembered that these signs and manifestations of heart failure can affect the course of pregnancy, the health of the baby and the woman.

If, after the electrocardiogram, there are abnormalities in the work of the heart, then ultrasound diagnostics is also shown.

Before conducting caesarean section under general anesthesia, a heart test is also prescribed.

With existing cardiovascular diseases or some of the above symptoms, an ultrasound diagnosis is mandatory. In the presence of cardiac pathology, the doctor must prescribe the necessary drugs to maintain the activity of the heart muscle, which will allow to bear and give birth to a healthy baby.

More information about ultrasound of the heart can be found in the video:

To determine the normal development of the fetus and the structure of all organs, intrauterine ultrasound is performed. A study is performed in the first trimester of pregnancy from 18 to 20 weeks. When detecting congenital abnormalities of the fetal heart, the doctor will determine the type of delivery. There are situations when, after giving birth, a baby needs an urgent operation and emergency medical care.

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An ultrasound of the heart, I was done only once and if earlier they had a mitral valve defect, then the ultrasound showed that the valve was normal, but a little soft, due to this it sags and there is a little noise.

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The content of this page is for informational and informational purposes only and cannot and does not constitute a public offer, which is determined by Art. No. 437 of the Civil Code of the Russian Federation. The information provided is for informational purposes only and does not replace examination and consultation with a doctor. There are contraindications and possible side effects, consult with a specialized specialist

Normal indicators of echocardiography, Doppler

Aortic valve: systolic leaflet divergence mm

Blood flow speed - up to 1.7 m / s

Pressure gradient - up to 11.6 mm Hg.

Right atrium -mm

Stroke volume - ml

ejection fraction - 56-64%

reduction fraction more than 27-41%

IVS - diastolic width - 7-11 mm, excursion - 6-8 mm

Diastolic divergence of the leaflets of the mitral valve - mm

The speed of the early diastolic covering of the anterior flap is 9-15 m / s.

Hole area - 4-6 sq. Cm

Blood flow speed - 0.6-1.3 m / sec.

The pressure gradient is 1.6-6.8 mm Hg. Art.

Tricuspid valve: blood flow velocity - 0.3-0.4 m / s

Pressure gradient - 0.4-2.0 mm Hg.

Blood flow speed - up to 0.9 m / sec.

Pressure gradient - up to 3.2 mm Hg. Art.

Pulmonary trunk diameter -mm

Determination of the severity of mitral stenosis and aortic stenosis:

The area of \u200b\u200bthe mitral opening is normally about 4 cm 2. With mitral stenosis, clinical symptoms appear when S \u003d 2.5 cm 2.

The severity of mitral stenosis, taking into account the area (S) of the mitral opening.

S\u003e 2 cm 2 - mild stenosis;

S \u003d 1-2 cm 2 - moderate stenosis (moderate);

S< 1 см 2 - значительный стеноз (тяжелой степени);

The severity of the aortic stenochus taking into account the S aortic opening.

S \u003d 1.5 cm 2 - initial aortic stenosis;

S \u003d 1.5-1.0 cm 2 - moderate aortic stenosis;

S < 1.0-0.8 cm 2 - severe aortic stenosis (severe);

Assessment of the severity of mitral and aortic stenosis taking into account

Assessment of the severity of mitral regurgitation (MR)

Ultrasound for everyone!

Mitral valve prolapse on ultrasound of the heart

Mitral valve prolapse is an abnormal prolapse (deflection) of one or both leaflets of the mitral valve into the left atrial cavity during left ventricular systole (contraction).

This condition can be due to a number of reasons: structural changes in the cusps, annulus fibrosus, chords, papillary muscles or impaired contractility of the left ventricular myocardium. A slight sagging of the leaflet or leaflets of the mitral valve can occur in people with asthenic constitution, and is not considered a serious pathology.

Echocardiography is the main method for diagnosing mitral valve prolapse. When performing the study, the doctor uses all the accesses and modes of echocardiography. With the help of ultrasound of the heart, it is possible to identify not only the prolapse of the valves, but also to assess their structure and functional features of the heart.

With ultrasound of the heart in one-dimensional mode, the following signs characteristic of mitral stenosis can be detected:

Thickening of the anterior, posterior, or both cusps of the mitral valve more than 5 mm, their hypoechoicity.

Let me explain right away what a one-dimensional mode in ultrasound is. It is also called M-mode. This is a study mode in which we get a picture of an organ cut. B - mode is a two-dimensional ultrasound mode. Just that three-dimensional image that everyone is used to.

Regurgitation is a return. It occurs when the heart valves do not close completely. At the same time, on ultrasound in duplex mode, we see this blood flow. Hemodynamically significant regurgitation means that this process causes a change in the parts of the heart - expansion of the cavities.

With B-mode ultrasound, the following signs of mitral valve prolapse are detected:

Sagging of one of the cusps or both cusps into the left atrial cavity in the left ventricular systole by more than 2 mm.

Sealing of the leaflets of the mitral valve.

Expansion of the mitral ring.

Tricuspid valve prolapse is also common.

With hemodynamically significant mitral regurgitation - an increase in the left heart.

With echocardiography, the degree of mitral valve prolapse is established.

I degree (minor prolapse) sagging of the valves from 3 to 5 mm.

III degree (moderately pronounced) sagging of the valves from 6 to 9 mm.

III degree (significantly pronounced) sagging of the valves more than 9 mm.

Color Doppler echocardiography may show mitral regurgitation. According to its severity, the degree of mitral valve prolapse is also specified.

The sagging of the mitral valve leaflet is clearly visible in B-ultrasound mode

Mitral and aortic heart valves - norms for ultrasound

Ultrasound examination is one of the most popular diagnostic methods in cardiology. Its advantages are convenience, high information content and accuracy. If you are worried about discomfort in the area of \u200b\u200bthe heart or have cardiac diseases, then do not postpone your visit to the doctor!

The anterior and posterior cusps, two commissures, chords and papillary muscles, and the mitral ring must be determined.

Mitral leaf thickness up to 2 mm;

The diameter of the annulus fibrosus is 2.0-2.6 cm;

The diameter of the mitral opening is 2-3 cm.

Mitral foramen area cm 2.

The circumference of the left atrioventricular opening is 6-9 cm;

The circumference of the left atrioventricular opening is inlet - 9.1-12 cm;

Active, but smooth movement of the valves;

Smooth flap surface;

The deflection of the valves into the left atrial cavity during systole is no more than 2 mm;

Chords are seen as thin, linear structures;

Some normal indicators:

Systolic opening of the valves is more painful;

Aortic orifice area cm 2.

The leaves are proportionally the same;

Full opening in systole, close well in diastole;

Aortic ring of medium uniform echogenicity;

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Ultrasound diagnostics of the heart: norms and ultrasound pathologies

The heart is one of the most important organs in maintaining life. Therefore, this body has a rather complex, both structural and functional organization. To diagnose heart disorders, many diagnostic methods have been invented or adapted: from examination to contrast tomography. However, not all methods can simultaneously show the state of both the structure and the operation of the most important motor in real time. Ultrasound diagnostics meets these requirements.

Indications and contraindications

Indications for an ultrasound examination of the heart are usually determined during the clinical examination.

Routine examination for newborns, adolescents during the period of intensive growth, athletes, as well as women when planning pregnancy
Heart rhythm disorders
Arterial hypertension
After suffering acute cardiovascular pathologies
Clinical signs of changes in the structure of the heart (expansion of the boundaries of the ventricles and atria, vascular bundle, pathological configuration, murmurs above the valve points)
ECG signs of abnormalities in the structure or function of the heart
If there is evidence for heart failure
For rheumatic diseases
If bacterial endocarditis is suspected
Suspected inflammatory disease of the heart or pericardium for another reason
Monitoring the dynamics of treatment or control before and after surgery on the heart
Control during pericardial puncture

There are currently no contraindications to cardiac ultrasound examination, as well as contraindications to ultrasound examination.

There are some limitations, for example, when performing a transthoracic ultrasound of the heart for people with severe subcutaneous fat or injuries in the area of \u200b\u200bthe procedure, with a pacemaker installed.

There is a difficulty in conducting ultrasound with increased airiness of the lungs, which, increasing, cover the heart, and the change in the phases of the environment reflects ultrasound.

Training

Before ultrasound of the heart, no special preparation is required, there is no need for diet or change in drinking regimen. It is important that anxiety during the procedure can somewhat distort the results, because the heart is an organ that is one of the first to respond to changes in mood.

The procedure is painless and safe, so there is no reason to worry. Also, before the ultrasound, it is not recommended to use substances that can affect the rhythm and conduction of the heart (do not smoke for 2 hours). When conducting a transesophageal ultrasound examination, there is a need for anesthesia: local anesthesia of the oral cavity is performed and, if necessary, general anesthesia for inserting the probe.

How is the diagnosis carried out?

Cardiac ultrasound can be done in a number of ways. The most common use of transthoracic and transesophageal methods.

With the transthoracic ultrasound method, the sensor is installed on the sternum area in its middle and lower thirds and on the left chest area. The examined person lies on his left side. A special acoustic gel is applied to the projection area of \u200b\u200bthe organ under investigation, which facilitates the ultrasound. The procedure usually lasts no more than half an hour.

Transesophageal ultrasound is performed after the ultrasound probe is inserted into the lumen of the esophagus. In the latter case, there are no obstacles for ultrasound examination in the form of lung tissue or possible pronounced subcutaneous fat.

The esophagus is very convenient for research, since it comes very close to the heart, and at the level of the left atrium it is adjacent to it directly, without the pericardium. However, the installation of the sensor into the esophagus can bring significant inconvenience to the patient, in such cases, specific preparation is required - general anesthesia.

Another way to perform ultrasound diagnostics of diseases of the cardiovascular system is stress echocardiography. This method involves conducting an ultrasound of the heart after stimulating its work. For this, special drugs or physical activity can be used.

This method is used in the diagnosis of ischemic heart disease, rhythm disturbances or functional insufficiency of the valves (when these disorders are caused under the supervision of a physician to identify and document it).

Doppler ultrasound is also worth it. This method is based on the reflection of ultrasound over a period of time from a point that has changed its position and is designed to detect violations of the blood flow, specifically for the heart - in its cavities. By determining the speed and direction of blood flow, it is possible to determine the state of the valves: normal, failure or stenosis.

Fetal heart diagnostics

To determine the state of the fetal heart, another method is used - cardiotocography, which examines the fetal heart rate, rhythm, acceleration and deceleration in order to identify intrauterine fetal hypoxia.

Research results: deviations and norms

Normal results

On ultrasound of the heart, the parameters of the aorta are first examined and evaluated. In the ascending section, its diameter normally does not exceed 40 mm. The pulmonary artery is normal within 11 - 22 mm.
Indicators of the left atrium: its size should be from 20 to 36 mm.
Right ventricle: wall thickness - 2-4 mm, diameter ranges from 7 to 26 mm.
Left ventricle: end diastolic diameter 37–55 mm,
end systolic diameter 26–37 mm,
diastolic volume 55-149 ml,
systolic volume 18-40 ml (respectively, ejection fraction 55-65%),
back wall thickness 9–11 mm.
The thickness of the interventricular septum is 9–10 mm (decreases slightly in systole).
The maximum blood flow velocity through the mitral valve 0.6 - 1.3 m / s,
through a tricuspid valve 0.3 - 0.7 m / s,
the area of \u200b\u200bthe left atrioventricular opening is about 5 cm², of the right - about 6 cm²,
the thickness of the flaps should be no more than 2 mm.
The valves are normally smooth, completely close in the systole of the ventricles and prolapse by no more than 2 mm, in the atrial systole they open without stenosis.
Aortic valve: opening area about 3-4 cm².

Ultrasound signs of pathologies

Arterial hypertension and symptomatic arterial hypertension (high blood pressure syndrome in other diseases) is characterized by a picture of thickening of the left ventricular wall. Finds that can cause hypertension are also possible: coarctation of the aorta (narrowing it after the left subclavian artery leaves the arch - at the site of the arterial ligament) or disruption of the normal functioning of the aortic valve (stenosis), enlargement of the aorta in the ascending section. In addition, atherosclerotic plaques found in the orifice of the aorta can be a cause of hypertension.
Valvular heart disease. Such disorders are characterized by stenosis of the valve openings, or vice versa, valve insufficiency. The mitral valve is most commonly affected.

Mitral valve stenosis

With its stenosis, the most important symptom will be a decrease in the area of \u200b\u200bthe left atrioventricular opening, early closure of the valve cusps (earlier than the cusps of the tricuspid valve), then there may be signs of a slowdown in valve opening during atrial systole, thickening of the left atrial wall, expansion of its cavity, much later - thickening of the walls of the right ventricle and right atrium, decrease in filling of the left ventricle and, accordingly, ejection into the aorta.

Lack of mitral valve

Such a pathology is characterized by the presence of reverse blood flow (regurgitation) into systole from the left ventricle back to the left atrium: in the easy stage it is 30% of the ejection fraction, in the middle - up to 50%, in the severe - most of the atrial volume is not filled with blood from the pulmonary veins, and from the left ventricle. Compensatory later, hypertrophy of the wall of the left ventricle and an increase in its cavity develop. Rheumatic diseases most often cause just such a heart defect.

Tricuspid valve pathology

Valve defects (stenosis and insufficiency) of the tricuspid valve are less common, their ultrasound signs are similar to those in mitral defects, with the exception of the absence of manifestations from the left heart in tricuspid stenosis.

Aortic malformations: Stenosis is characterized by a decrease in the area of \u200b\u200bthe aortic opening, over time, thickening of the left ventricular myocardium develops in order to resist the resistance of the leaflets. Aortic insufficiency is characterized by incomplete closure of the valve in diastole and, accordingly, partial regurgitation of blood into the left ventricular cavity. The indicators are the same: 30% casting - for mild severity, 30-50% for moderate severity and more than 50% - severe aortic insufficiency (ultrasound also determines the length of the blood stream thrown into the left ventricle: according to the severity of 5 mm, 5 –10 mm and more than 10 mm).
Pulmonary valve defects are similar in manifestations to aortic ones, but they are much less common.
Bacterial endocarditis creates a picture of (usually) aortic insufficiency due to changes in the normal configuration of the valve leaflets. In addition to the changes in the heart, characteristic of aortic insufficiency, the ultrasound picture of the valves reveals bacterial vegetations, which are the basis for the diagnosis.
Postinfarction condition.

Myocardial infarction is usually diagnosed using faster, easier ECG tests that diagnose an acute condition and initiate emergency procedures. Therefore, ultrasound is used more to assess the damage done to the heart muscle by the pathological process and to clarify the focus of the heart attack.

Localization of the focus - determination of the zone of altered echogenicity of the left ventricular wall, including scar tissue and areas with reduced or absent motor activity.

Complications of myocardial infarction, detected by ultrasound, can be: aneurysm of the heart (protrusion of the thinned wall of the left ventricle into the pericardial cavity), rupture of the interventricular septum (equalization of blood pressure in the left and right ventricles), rupture of the heart wall and tamponade (filling the cavity of the heart bag with blood, an increase in pressure there and a violation of the heart), rupture of the papillary muscle (it holds the leaf of the mitral valve, respectively, when a muscle breaks on ultrasound, signs of valve failure) and others.

After a suffered myocardial infarction or in its acute period, conduction or rhythm disturbances of heart contractions may appear.

Violations of the rhythm and conduction of the myocardium.

Again, electrocardiography is decisive in making the diagnosis, however, ultrasound can be used to clarify the nature of the violation: clarify the rhythm of contraction of individual chambers, identify changes in the structure of the myocardium (postinfarction scar), which can cause various conduction disorders, extrasystoles.

Pericarditis is dry (inflammation of the pericardial sac), effusion (fluid appears in the cavity - exudate) and constrictive (after effusion, fibrin adhesions can form between the pericardial layers, which limit the movement of the heart). It is better on ultrasound to determine precisely the accumulation of fluid, which looks like an expansion of the hypoechoic strip around the heart. Also, the task of ultrasound is to control the passage of the puncture needle for aspiration of this fluid.

Conclusion

Ultrasound today is an almost universal method for studying disorders in different systems organism, including cardiovascular. ECHO of the heart is successfully used to identify both organic and functional heart pathologies.

Cardiology ultrasound of the heart

Deciphering the normal indicators of ultrasound of the heart

Examination of internal organs using ultrasound is considered one of the main diagnostic methods in various fields of medicine. In cardiology, ultrasound of the heart is better known as echocardiography, which allows you to identify morphological and functional changes in the work of the heart, anomalies and disorders in the valve apparatus.

Echocardiography (Echo KG) - refers to non-invasive diagnostic methods, which is very informative, safe and is performed for people of different age categories, including newborns and pregnant women. This method of examination does not require special training and can be carried out at any convenient time.

Unlike X-ray examination, (Echo KG) can be performed several times. It is completely safe and allows the attending physician to monitor the patient's health and the dynamics of cardiac pathologies. During the examination, a special gel is used, which allows ultrasound to better penetrate the heart muscles and other structures.

What allows you to examine (EchoCG)

Ultrasound of the heart allows the doctor to determine many parameters, norms and deviations in the work of the cardiovascular system, to assess the size of the heart, the volume of cardiac cavities, wall thickness, frequency of strokes, the presence or absence of blood clots and scars.

Also, this examination shows the state of the myocardium, pericardium, large vessels, the mitral valve, the size and thickness of the walls of the ventricles, determines the state of the valve structures and other parameters of the heart muscle.

After the performed (Echo KG), the doctor records the results of the examination in a special protocol, the decoding of which makes it possible to detect cardiac diseases, deviations from the norm, anomalies, pathologies, and also to diagnose and prescribe the appropriate treatment.

When to do (Echo KG)

The earlier the pathologies or diseases of the heart muscle are diagnosed, the more chances of a positive prognosis after treatment. An ultrasound scan should be performed with the following symptoms:

recurrent or frequent heart pain;
rhythm disturbances: arrhythmia, tachycardia;
dyspnea;
increased blood pressure;
signs of heart failure;
transferred myocardial infarction;
if there is a history of heart disease;

It is possible to undergo this examination not only in the direction of a cardiologist, but also other doctors: endocrinologist, gynecologist, neurologist, pulmonologist.

What diseases is diagnosed by ultrasound of the heart

There are a large number of diseases and pathologies that are diagnosed by echocardiography:

ischemic disease;
myocardial infarction or pre-infarction condition;
arterial hypertension and hypotension;
congenital and acquired heart defects;
heart failure;
rhythm disturbances;
rheumatism;
myocarditis, pericarditis, cardiomyopathy;
vegetative - vascular dystonia.

An ultrasound examination can also detect other disorders or diseases of the heart muscle. In the protocol of the diagnostic results, the doctor makes a conclusion, which displays the information received from the ultrasound machine.

These examination results are examined by the attending physician, a cardiologist, and in the presence of deviations, prescribes therapeutic measures.

Decoding an ultrasound of the heart consists of multiple points and abbreviations that are difficult to make out for a person who does not have a special medical education, so we will try to briefly describe the normal indicators obtained by a person who has no abnormalities or diseases of the cardiovascular system.

Echocardiography interpretation

Below is a list of abbreviations that are recorded in the protocol after the examination. These indicators are considered the norm.

Left ventricular myocardial mass (LVMM):
Left ventricular myocardial mass index (LVMI): g / m2;
End-diastolic volume of the left ventricle (EDV): 112 ± 27 (65-193) ml;
End-diastolic size (CRS): 4.6 - 5.7 cm;
End systolic dimension (EDS): 3.1 - 4.3 cm;
Wall thickness in diastole: 1.1 cm
Long axis (DO);
Short axis (KO);
Aorta (AO): 2.1 - 4.1;
Aortic valve (AK): 1.5 - 2.6;
Left atrium (LP): 1.9 - 4.0;
Right atrium (PR); 2.7 - 4.5;
Diastological thickness of the myocardium of the interventricular septum (TMMZhPd): 0.4 - 0.7;
Systological thickness of the myocardium of the interventricular septum (TMMZhPS): 0.3 - 0.6;
Ejection fraction (EF): 55-60%;
Miltral valve (MK);
Myocardial movement (DM);
Pulmonary artery (PA): 0.75;
Stroke volume (SV) - the amount of blood volume ejected by the left ventricle in one contraction: ml.
Diastolic size (DR): 0.95-2.05 cm;
Wall thickness (diastolic): 0.75-1.1 cm;

After the results of the examination, at the end of the protocol, the doctor makes a conclusion in which he reports on the deviations or norms of the examination, and also notes the alleged or exact diagnosis of the patient. Depending on the purpose of the examination, the state of health of the person, the age and sex of the patient, the examination may show slightly different results.

The complete echocardiography transcript is evaluated by a physician cardiologist. An independent study of the parameters of cardiac indicators will not give a person complete information on assessing the health of the cardiovascular system, if he does not have special education. Only an experienced doctor in the field of cardiology will be able to decipher echocardiography and answer the patient's questions of interest.

Some indicators are able to deviate slightly from the norm or be recorded in the examination protocol under other items. It depends on the quality of the device. If the clinic uses modern equipment in 3D, 4D images, then more accurate results can be obtained, on which the patient will be diagnosed and treated.

Ultrasound of the heart is considered a necessary procedure, which should be carried out once or twice a year for prophylaxis, or after the first ailments from the cardiovascular system. The results of this examination allow a specialist doctor to detect cardiological diseases, disorders and pathologies in the early stages, as well as to carry out treatment, give useful recommendations and return a person to a full life.

Heart ultrasound

The modern world of diagnostics in cardiology offers various methods that allow timely identification of pathologies and deviations. One of these methods is ultrasound of the heart. This examination has many advantages. This is high information content and accuracy, convenience of conducting, minimum possible contraindications, lack of complex preparation. Ultrasound examinations can be performed not only in specialized departments and offices, but even in the intensive care unit, in ordinary wards of the department or in an ambulance car for urgent hospitalization of a patient. Various portable devices, as well as the latest equipment, help in this ultrasound of the heart.

What is heart ultrasound

With the help of this examination, a specialist in ultrasound diagnostics can obtain an image from which he determines the pathology. For these purposes, special equipment is used, which has an ultrasonic sensor. This sensor is tightly attached to the patient's chest, and the resulting image is displayed on the monitor. There is a concept of "standard positions". This can be called a standard "set" of images required for examination so that the doctor can formulate his conclusion. Each position implies a different sensor position or access. Each position of the sensor gives the doctor the opportunity to see different structures of the heart, to examine the vessels. Many patients notice that during an ultrasound of the heart, the sensor is not only placed on the chest, but also tilted or rotated, which allows you to see different planes. In addition to standard accesses, there are additional ones. They are used only when needed.

What diseases can be detected

The list of possible pathologies that can be seen on ultrasound of the heart is very large. We list the main diagnostic capabilities of this examination:

coronary heart disease;
examinations for arterial hypertension;
aortic disease;
diseases of the pericardium;
intracardiac formations;
cardiomyopathy;
myocarditis;
endocardial damage;
acquired valvular heart disease;
examination of mechanical valves and diagnosis of dysfunction of valve prostheses;
diagnosis of heart failure.

For any complaints of feeling unwell, with pain and discomfort in the heart area, as well as with other symptoms that disturb you, you should consult a cardiologist. It is he who makes the decision about the examination.

Heart ultrasound rates

It is difficult to list all the norms of ultrasound of the heart, but we will touch on some.

mitral leaflet thickness up to 2 mm;
the diameter of the annulus fibrosus - 2.0-2.6 cm;
the diameter of the mitral opening is 2-3 cm.
the area of \u200b\u200bthe mitral opening is 4 - 6 cm2.
the circumference of the left atrioventricular opening is 6-9 cm;
the circumference of the left atrioventricular opening is inlet - 9.1-12 cm;
active, but smooth movement of the valves;
smooth flap surface;
deflection of the valves into the left atrial cavity during systole is not more than 2 mm;
the chords are seen as thin, linear structures.

Some normal indicators:

systolic opening of the valves is more painful;
the area of \u200b\u200bthe aortic opening is 2 - 4 cm2.
the flaps are proportionally the same;
full opening in systole, close well in diastole;
aortic ring of medium uniform echogenicity;

Tricuspid (tricuspid) valve

the valve opening area is 6-7 cm2;
the sashes can be split, reaching a thickness of up to 2 mm.

the thickness of the posterior wall in diastole is 8-11 mm, and the interventricular septum is 7-10 cm.
the mass of the myocardium in men is 135 g, the mass of the myocardium in women is 95 g.

Nina Rumyantseva, 02/01/2015

Ultrasound examination of the heart

Ultrasound examination in cardiology is the most significant and widespread research method, which occupies a leading position among non-invasive procedures.

Ultrasound diagnostics has great advantages: the doctor receives objective reliable information about the state of the organ, its functional activity, anatomical structure in real time, the method makes it possible to measure almost any anatomical structure, while remaining absolutely harmless.

However, the results of the study and their interpretation directly depend on the resolution of the ultrasound apparatus, on the skills, experience and acquired knowledge of the specialist.

Ultrasound of the heart, or echocardiography, makes it possible to visualize organs, great vessels on the screen, to assess the blood flow in them using ultrasound waves.

Cardiologists use different modes of the apparatus for research: one-dimensional or M-mode, D-mode, or two-dimensional, Doppler echocardiography.

Currently, modern and promising methods of examining patients using ultrasonic waves have been developed:

Echo-KG with three-dimensional image. Computer summation of a large number of two-dimensional images obtained in several planes results in a three-dimensional image of the organ.
Echo-KG using a transesophageal transducer. A one- or two-dimensional sensor is placed in the examinee's esophagus, with the help of which basic information about the organ is obtained.
Echo-KG using an intracoronary transducer. A high-frequency ultrasonic sensor is placed in the cavity of the vessel to be examined. Gives information about the lumen of the vessel and the state of its walls.
Contrast application in ultrasound examination. The image of the structures to be described is improved.
High resolution ultrasound of the heart. The increased resolution of the device makes it possible to obtain a high quality image.
M-mode anatomical. One-dimensional image with spatial plane rotation.

Research methods

Diagnosis of cardiac structures and large vessels is carried out in two ways:

The most common is transthoracic, through the anterior surface of the chest. The transesophageal method is referred to as more informative, since it can be used to assess the condition of the heart and large vessels from all possible angles.

Ultrasound of the heart can be supplemented with functional tests. The patient performs the proposed physical exercises, after or during which the result is deciphered: the doctor assesses the changes in the structures of the heart and its functional activity.

The study of the heart and large vessels is complemented by dopplerography. It can be used to determine the speed of blood flow in the vessels (coronary, portal veins, pulmonary trunk, aorta).

In addition, Doppler shows the blood flow inside the cavities, which is important in the presence of defects and for confirming the diagnosis.

There are certain symptoms that indicate the need to visit a cardiologist and have an ultrasound scan:

Lethargy, the appearance or increased shortness of breath, fatigue.
A feeling of palpitations, which can be a sign of an irregular heartbeat.
The limbs get cold.
The skin often turns pale.
The presence of a congenital heart defect.
Poorly or slowly, the child is gaining weight.
The skin is bluish (lips, fingertips, auricles and nasolabial triangle).
The presence of a heart murmur during a previous examination.
Acquired or congenital defects, the presence of a valve prosthesis.
A tremor is distinctly felt above the apex of the heart.
Any signs of heart failure (shortness of breath, edema, distal cyanosis).
Heart failure.
Palpable “heart hump”.
Ultrasound of the heart is widely used to study the structure of the tissues of an organ, its valve apparatus, to detect fluid in the pericardial cavity (pericardial effusion), blood clots, and to study the functional activity of the myocardium.

Diagnosis of the following diseases is impossible without ultrasound examination:

Different degrees of manifestation of ischemic disease (myocardial infarction and angina pectoris).
Inflammation of the cardiac membranes (endocarditis, myocarditis, pericarditis, cardiomyopathy).
All patients are shown diagnostics after suffering myocardial infarction.
In diseases of other organs and systems that have a direct or indirect damaging effect on the heart (pathology of the peripheral bloodstream of the kidneys, organs located in the abdominal cavity, the brain, in diseases of the vessels of the lower extremities).

Modern devices for ultrasound diagnostics make it possible to obtain many quantitative indicators with the help of which it is possible to characterize the main cardiac function of contraction. Even the early stages of a decrease in myocardial contractility can be detected by a good specialist and therapy can be started on time. And to assess the dynamics of the disease, ultrasound examination is repeated, which is also important to check the correctness of the treatment.

What preparation includes before the study

More often, the patient is assigned a standard method - transthoracic, which does not require special preparation. The patient is only advised to remain emotionally calm, since excitement or previous stress can affect the diagnostic results. For example, heart rate increases. It is also not recommended to eat a large meal before an ultrasound of the heart.

A little stricter preparation before carrying out a transesophageal ultrasound of the heart. The patient should not take food 3 hours before the procedure, and infants should be examined during the breaks between feeding.

Echocardiography

During the examination, the patient lies on his left side on a couch. This position will bring the cardiac apex and the anterior chest wall closer together, thus, the four-dimensional image of the organ will be more detailed.

Such a survey requires technically sophisticated and high-quality equipment. Before attaching the probes, the doctor applies the gel to the skin. Special sensors are located in different positions, which will allow visualizing all parts of the heart, assessing its work, changes in structures and valve apparatus, and measuring parameters.

The sensors emit ultrasonic vibrations that are transmitted to the human body. The procedure does not cause even the slightest discomfort. The altered acoustic waves are returned to the device through the same sensors. At this level, they are converted into electrical signals processed by an echocardiograph.

The change in the type of wave from the ultrasonic sensor is associated with changes in the tissues, changes in their structure. The specialist receives a clear picture of the organ on the monitor screen; at the end of the study, the patient is provided with a transcript.

Otherwise, transesophageal manipulation is performed. The need for it arises when some "obstacles" interfere with the passage of acoustic waves. This can be subcutaneous fat, chest bones, muscles, or lung tissue.

Transesophageal echocardiography is available in three dimensions, with the transducer inserted through the esophagus. The anatomy of this area (the junction of the esophagus with the left atrium) makes it possible to obtain a clear image of the small anatomical structures.

The method is contraindicated in diseases of the esophagus (strictures, varicose veins its venous bed, inflammation, bleeding or the risk of their development during manipulation).

Mandatory before transesophageal Echo-KG is fasting for 6 hours. The specialist does not hold the sensor for more than 12 minutes in the study area.

Indicators and their parameters

After the end of the study, the patient and the attending physician are provided with a transcript of the results.

The values \u200b\u200bmay have age characteristics, as well as different indicators for men and women.

Obligatory indicators are: parameters of the interventricular septum, left and right heart, the state of the pericardium and the valve apparatus.

Left ventricle rate:

The mass of his myocardium ranges from 135 to 182 grams in men, and from 95 to 141 grams in women.
Left ventricular myocardial mass index: for men from 71 to 94 grams per m², for women from 71 to 80.
The volume of the left ventricular cavity at rest: in men from 65 to 193 ml, for women from 59 to 136 ml, the size of the left ventricle at rest is from 4.6 to 5.7 cm, during contraction, the norm is from 3.1 to 4, 3 cm.
The thickness of the walls of the left ventricle does not normally exceed 1.1 cm; an increase in the load leads to hypertrophy of muscle fibers, when the thickness can reach 1.4 cm or more.
Ejection fraction. Its rate is not less than 55-60%. This is the volume of blood that the heart ejects with each contraction. A decrease in this indicator speaks of heart failure, symptoms of blood stagnation.
Impact volume. The norm from 60 to 100 ml also shows how much blood is thrown out in one contraction.

The thickness of the interventricular septum is from 10 to 15 mm in systole and 6 to 11 mm in diastole.
The diameter of the aortic lumen is from 18 to 35 mm in norm.
The wall thickness of the right ventricle is from 3 to 5 mm.

The procedure lasts no more than 20 minutes, all data about the patient and the parameters of his heart are stored in electronic form, and a decryption is given to the hands, understandable for the cardiologist. The reliability of the technique reaches 90%, that is, already in the early stages it is possible to identify the disease and begin adequate treatment.

The physical properties of ultrasound determine the methodological features of echocardiography. Ultrasound of the frequency used in medicine practically does not pass through the air - An insurmountable obstacle in the path of the ultrasound beam can be the lung tissue between the chest and heart, as well as a small air gap between the surface of the sensor and the skin. To eliminate the last obstacle, a special gel is applied to the skin, displacing the air from under the sensor. To exclude the influence of the lung tissue, the points where the heart is directly adjacent to the chest are chosen for the transducer installation - the "ultrasound window". This is the zone of absolute cardiac dullness (3-5 intercostal space to the left of the sternum), the so-called parasternal approach, and the zone of the apical impulse (apical approach). There is also a subcostal approach (at the xiphoid process in the hypochondrium) and suprasternal (in the jugular fossa above the sternum). The sensor is installed in the intercostal space due to the fact that ultrasound does not penetrate deep into the bone tissue, being completely reflected from it. In children's practice, due to the absence of ossification of cartilage, it is possible to study through the ribs.

During the study, the patient usually lies on his back with a raised upper body, but sometimes for better adherence of the heart to the chest wall, a lying position on the left side is used.

In patients with lung diseases accompanied by emphysema, as well as in people with other causes of the "small ultrasound window" (massive chest, calcification of costal cartilage in the elderly, etc.), echocardiography becomes difficult or impossible. Difficulties of this kind are encountered in 10-16% of patients and are the main disadvantage of this method.

Ultrasound anatomy of the heart in various echolocation modes

I. Univariate (M-) echocardiography.

For the unification of studies in echocardiography, 5 standard positions are proposed, i.e. directions of the ultrasound beam from the parasternal access. Mandatory for any research are 3 of them (Fig. 3).

Figure: 3. Basic standard transducer positions for univariate echocardiography (M-mode).

Position I - the ultrasound beam is directed along the short axis of the heart and passes through the right ventricle, the interventricular septum, the cavity of the left ventricle at the level of the tendon filaments of the mitral valve, the posterior wall of the left ventricle.

The standard position of transducer II is by tilting the transducer slightly higher and more medially, the beam will pass through the right ventricle, the left ventricle at the level of the mitral valve leaflets.

N.M. Mukharlyamov (1987) gives the numbering of standard positions in the reverse order, since the study in M-mode begins more often with echolocation of the aorta, then tilting the transducer downward in other positions.

Image of heart structures in I standard position.

In this position, information is obtained about the size of the ventricular cavities, the thickness of the walls of the left ventricle, impaired myocardial contractility and the value of cardiac output (Fig. 4).

Pancreas - the cavity of the right ventricle in diastole (norm up to 2.6 cm)

Tmzhp - top of the interventricular septum in diastole

Tzslzh (d) - the thickness of the posterior wall of the left ventricle in diastole

CRA - end-diastolic size of the left ventricle

DAC - end-systolic size of the left ventricle

Pxs. 4. M - echocardiogram in I standard position of the transducer.

During systole, the right ventricle and interventricular septum (IVS) move from the transducer to the left ventricle. The posterior wall of the left ventricle (LVLV), opposite. moves towards the sensor. In diastole, the direction of movement of these structures is reversed, and the diastolic velocity of the ZSLZH is normally 2 times higher than the systolic. The endocardium of the ZSLZ therefore describes a wave with a gentle ascent and a steep descent. The epicardium of the ZSLZh makes a similar movement, but with a smaller amplitude. Before the systolic rise of the ZSLZh, a small notch a is recorded, due to the expansion of the left ventricular cavity during atrial systole.

The main indicators measured in the I stationary position.

1. End-diostolic size (EDD) of the left ventricle (end dinstolic diameter, EDD) - the distance in diastole along the short axis of the heart between the endocardium of the ZSLZH and IVS at the level of the beginning complex QRS synchronously recorded ECG. EDR is normally 4.7-5.2 cm.An increase in EDR is observed with dilatation of the left ventricular cavity, a decrease - with diseases leading to a decrease in its volume (mitral stenosis, hypertrophic

Cardiomyopathy).

2. End systolic diameter (ESD) of the left ventricle (end systolic diameter, ESD) - the distance at the end of systole between the endocardial surfaces of the ZSLV and IVS in the place of the highest point of ascent of the ZSLV. DAC is in the middle, it is 3.2-3.5 cm. DAC increases with dilatation of the left ventricle, with impaired contractility. A decrease in the CVR occurs, in addition to the reasons for the decrease in the CVR, in case of insufficiency of the mitral valve (due to the volume of regurgitation).

Taking into account the fact that the left ventricle is an ellipsoid in shape, it is possible to determine its volume by the size of the short axis. The most commonly used formula is L. Teicholtz et al. (1972).

= 7,0 * 3

V (24 * D) D (cm3),

where D is the anteroposterior dimension in systole or diastole.

The difference between the end-diastolic volume (EDV) and the end-systolic volume (ESV) will give the stroke volume ( UO):

UO - KDO - KSO (ml).

Knowing heart rate, body area ( St), you can determine other hemodynamic parameters.

Impact index (UI):

UI \u003d UO / St

Minute blood circulation ( IOC):

IOC \u003d VO heart rate

Cardiac index ( SI): SI = IOC/ St

3. The thickness of the ZSLYAS in diastole (Tzslzh (d)) is normally 0.8-1.0 cm and increases with hypertrophy of the walls of the left ventricle.

4. The thickness of the ZSLZh in systole (Tzslzh (s)) the average is 1.5-1.8 cm. A decrease in Tzslzh (s) is observed with a decrease in myocardial contractility.

To assess the contractility of a given part of the myocardium, an indicator of its systolic thickening is often used - the ratio of diastolic thickness to systolic thickness. The norm Tzslzh (d) / Tzslzh (s) is about 65%. An equally important indicator of the local contractility of the myocardium is the magnitude of its systolic excursion, i.e. amplitude of movement of the endocardium during contraction of the heart. Systolic excursion of the ZSLZH is normal - I see. Reduction of systolic excursion (hypokinesis) up to complete immobility (myocardial akinesia) can be observed with lesions of the heart muscle of various etiologies (IBO, cardiomyopathy, etc.). An increase in the amplitude of myocardial movement (hyperkinesis) is observed with insufficiency of the moral and aortic valves, hyperkinetic syndrome (anemia, thyrotoxicosis, etc.). Local hyperkinesis is often defined in IHD in the intact zones of the myocardium as a compensatory mechanism in response to a decrease in contractility in the affected areas.

5. The thickness of the interventricular septum in diastole (TMZhp (d)) is normal 0.6-0.8 cm.

6. The systolic excursion of the IVS is normally 0.4-0.6 cm and is usually half the excursion of the IVS. The reasons for IVS hypokinesis are similar to the reasons for the decrease in systolic excursion of the LVP. In addition to the aforementioned causes of hyperkinesis of LVWS, moderate IVS hyperkinesis can result in myocardial dystrophy of various etiologies in the initial stages of the disease.

In some diseases, the movement of the interventricular - the septum changes to the opposite - not towards the ZSLZH, as is observed in the norm, but parallel to it. This form of IVS movement is called "paradoxical" and occurs in severe left ventricular hypertrophy. "Parodox" movement of a limited area (IVS, apex, lateral wall); its "bulging" in systole, in contrast to the contraction of adjacent zones of the myocardium, is observed with left ventricular aneurysms.

To assess the contractility of the myocardium, in addition to the measurements of the heart walls described above and the calculation of hemodynamic volumes, several highly informative indicators have been proposed (Pombo J. et al., 1971):

1. Ejection fraction is the ratio of the stroke volume to the value of the end diastolic volume, expressed as a percentage or (less often) in the form of a decimal fraction:

FV \u003d UO / KDO 100% (norm 50-75%)

2. The degree of shortening of the anteroposterior size of the left ventricle in systole (% ΔS):

% ΔS \u003d KDR-KSR / KDR 100% (norm 30-43%)

3. The rate of pyrculatory shortening of myocardial fibers

(Vcf). To calculate this indicator, it is first necessary to determine the ejection time of the left ventricle from the echogram, which is measured at the beginning of the systolic rise of the LVPW endocardium to its apex (Fig. 4).

Vcf \u003dKDR-KSR/ Tee KDR (env/ from) where Tee - period of exile

Normal value Vcf 0.9-1.45 (env / s sludge s-1).

A feature of all measurements in the 1st standard position is the need to direct the ultrasound beam strictly perpendicular to the IVS and ZSLZH, i.e. along the short axis of the heart. If this condition is not observed, the measurement results will be overestimated or underestimated. To eliminate such errors, it is desirable to first obtain a two-dimensional image of the heart along the long axis from the parasteral approach, then, under the control of the resulting B-scan, position the cursor in the desired position and unfold the image in M-mode.

Image of heart structures in standard II position of the sensor (Fig. 5)

The ultrasound beam passes through the edges of the mitral valve cusps (MC), the movement of which provides basic information about the condition of the cusps and the violation of the transmitral blood flow.

During the systole of the ventricles, the valves are closed and fixed in a single line (SD interval). At the beginning of diastole (point D), blood begins to flow from the atria into the ventricles, opening the valves. In this case, the front flap moves up to the X sensor (interval D-E), the rear flap moves down in the opposite direction. At the end of the period of rapid filling, the amplitude of the divergence of the valves is maximum (point E). Then the intensity of blood flow through the mitral foramen decreases, which leads to partial covering of the leaflets (point F) in the middle of diastole. At the end of diastole, the transmitral blood flow increases again due to atrial contraction, which is reflected on the echogram by the second peak of leaflet opening (point A). In the future, the valves are completely closed in the systole of the ventricles and the cycle is repeated.

Fig 5. M-echocardiogram in the II standard position of the transducer .

Thus, due to the unevenness of the transmitral blood flow ("biphasic" filling of the left ventricle), the movement of the cusps of the moral valve is represented by two peaks. The form of movement of the front sash resembles the letter "M", the back - "W". The posterior valve of the MC is smaller than the front one; therefore, the amplitude of its opening is small, and its visualization is often difficult.

Clinically, both peaks of diastolic ventricular filling can manifest themselves, respectively, with III and IV heart sounds.

The main indicators of an echocardiogram in the II standard position

The amplitude of the diastolic opening of the anterior cusp of the "playing valve (vertical displacement of the interval D-E) - the norm is 1.8 cm.

Diastolic divergence of the leaflets (at the height of peak E) is the norm of 2.7 cm. The values \u200b\u200bof both indicators decrease with mitral stenosis and may increase slightly with "pure" mitral valve insufficiency.

The speed of early diastolic closure of the anterior moral cusp (determined by the slope of the E-F section). A decrease in speed (normally 13-16 cm / s) is one of the sensitive signs of the early stages of mitral stenosis.

The duration of the diastolic divergence of the mitral cusps (from the moment the cusps open to the point of closure in the D-C interval) is the norm of 0.47 s. In the absence of tachycardia, a decrease in this indicator may indicate an increase in end-diastolic pressure in the left.

ventricle (LVEDD). 5. Speed \u200b\u200bof diastolic. Anterior cusp opening

(determined by the slope of the D-E section and is normally 27.6 cm / s) - A decrease in the opening speed of the valves can also be an indirect sign of an increase in LVEDD.

Image of heart structures in the III standard position of the sensor (Fig. 6).

The echogram in this position gives information about the state of the aortic root, aortic valve cusps, and the left atrium.

Figure: 6. M-echocardiogram in the W standard position of the transducer.

The ultrasound beam, passing through the anterior and posterior walls of the base of the aorta, produces an image in the form of two parallel wavy lines. Above the anterior machine of the aorta is the outlet tract of the right ventricle, below the posterior wall of the aortic root, which is simultaneously the anterior wall of the left atrium, is the cavity of the left atrium. The movement of the walls of the aorta in the form of parallel wills arises due to the displacement of the aortic root together with the annulus fibrosus anteriorly to the sensor during systole.

In the lumen of the base of the aorta, the movement of the aortic valve cusps (usually the right coronary cusp from above and the left coronary valve from below) is recorded. During the expulsion of blood from the left ventricle, the right coronary valve opens forward towards the transducer (upward on the echogram), the left coronary valve opens in the opposite direction. During the entire systole, the valves are in a fully open state, adjacent to the walls of the aorta, and are recorded on the echogram in the form of two parallel lines located at a short distance from the anterior and posterior walls of the aorta, respectively.

At the end of the systole, the valves quickly close and close, moving towards each other. As a result, the cusps of the aortic valve during systole of the left ventricle describe a figure resembling a "box". The upper and lower walls of this "box" are formed by echo signals from the aortic leaflets completely open during the expulsion period, and the "side walls" are formed by the divergence and closing of the valve leaflets. In diastole, the aortic valve leaflets are closed and fixed in a single line parallel to the walls of the aorta and located in the center of its lumen. The form of movement of the closed valves resembles a "snake" due to fluctuations in the base of the aorta at the beginning and at the end of the diastole of the ventricles.

Thus, characteristic form normal movement of the aortic valve leaflets is the alternation of "capsule" and "snake" in the lumen of the base of the aorta.

The main indicators recorded in the III standard position of the sensor.

The lumen of the base of the aorta is determined by the distance between the inner surfaces of the walls of the aorta in the middle or at the end of diastole and does not normally exceed 3.3 cm.Expansion of the lumen of the aortic root is observed in congenital defects (tetrad of Fallot), Marfan syndrome, aortic aneurysms of various localization.
Systolic divergence of the aortic valve leaflets - the distance between the open leaflets at the beginning of the systole; normally 1.7-1.9 cm. The opening of the valves is reduced with stenosis of the aortic opening.
Systolic excursion of the walls of the aorta - the amplitude of the displacement of the aortic root during systole. Normally, it is about 1 cm for the posterior wall of the aorta and decreases with a decrease in cardiac output.
The size of the left atrial cavity is measured at the very beginning of the ventricular diastole at the site of the greatest displacement of the aortic root to the sensor. Normally, the atrial cavity is approximately equal to the diameter of the base of the aorta (the ratio of these dimensions is not more than 1.2) and does not exceed 3.2 cm. Significant dilation of the left atrium (cavity size of 5 cm or more) is almost always accompanied by the development of a permanent form of atrial fibrillation.

II. Two-dimensional echocardiography.

Image of heart structures in longitudinal section along the long axis of the heart from parasternal access (Fig. 7)

1 - psmk; 2 - zsmk; 3 - papillary muscle; 4 - chords.

Fig 7. Two-dimensional echocardiogram in section along the long axis from the parasternal approach.

In this projection, the base of the aorta, the movement of the aortic valve cusps, the cavity of the left atrium, the mitral valve, and the left ventricle are well visualized. Normally, the leaflets of the aortic and mitral valves are thin, moving in opposite directions. In case of defects, the mobility of the valves decreases, the thickness to the echogenicity of the valves increases due to sclerotic changes. Hypertrophy of the heart is determined in this projection by changes in the corresponding cavities and walls of the ventricles.

Cross-section from the parasternal approach along the short axis at the level of the edges of the mitral leaflets (Fig. 8)

1- PSMK; 2- ZSMK.

Figure: 8. Section along the short axis from the parasternal approach at the level of the edges of the open mitral valves.

The left ventricle in this section looks like a circle, to which the right ventricle is adjacent in front in the form of a crescent. The projection gives foam information about the size of the left atrioventricular opening, which is normally 4-6 cm2. The distance between the commissures is normally somewhat larger than between the valves at the time of their maximum opening. In rheumatism, due to the development of adhesions in the commissures, the intercommissural size may turn out to be smaller than the intervalvular one. In modern echocardiographs, it is possible not only to determine the size, but also to directly measure the area of \u200b\u200bthe mitral opening and its perimeter (Noshu W.L. et al., 197S).

Cross-section from the parasternal approach along the short axis of the heart at the level of the base of the aorta (Fig. 9)

1-right coronary valve;

2-left coronary valve;

3-non-coronary sash.

Figure: 9. Section along the short axis from the parasternal approach at the level of the aortic root.

In the center of the image, we see a round cut through the aorta and all 3 aortic valve cusps. Under the aorta are the cavities of the left and right atria, above the aorta in the form of an arc - the cavity of the right ventricle. The atrial septum and tricuspid valve are visualized, and with a greater tilt of the sensor, one of the pulmonary valve leaflets.

Projection of 4 heart chambers from the apical approach (Fig. 10)

1-interatrial septum

2-interventricular septum

Figure: 10. Scheme of a two-dimensional echogram from the apical approach in the projection of 4 cameras.

The sensor is installed above the apex of the heart, so the image on the screen appears to be "inverted": atria below, ventricles on top. In this projection, aneurysms of the left ventricle, some congenital defects (defects of the interventricular and interatrial septa) are well visualized.

Echocardiogram for certain heart conditions.

Rheumatic heart disease.

Mitral stenosis.

Rheumatic endocarditis leads to morphological changes in the mitral valve: the leaflets grow together along the commissures, thicken, and become inactive.

Tendon filaments are fibrously changed and shortened, papillary muscles are affected. Deformation of the leaflets and disturbance of the transmitral blood flow lead to a change in the shape of the leaflet movement, determined on the echogram. As the stenosis progresses, the mitral blood flow ceases to be "biphasic", as is normal, and becomes constant through the narrowed opening throughout the diastole.

In this case, the leaflets of the mitral valve do not close in the middle of the diastole and are in the maximum open state throughout its length. On a one-dimensional echogram, this is manifested by a decrease in the speed of early diastolic closure of the valves (inclination of the EF section) and the transition from the normal M-shaped movement of the valves to the U-shaped one with pronounced stenosis. Clinically, in such a patient, the protodiastolic and presystolic murmur corresponding to the E- and A-peaks of the M-echogram of the mitral valve turns into a noise that occupies the entire diastole. In fig. 11 shows the dynamics of a one-dimensional echogram of the mitral valve with the development of moderate and severe mitral stenosis. Moderate stenosis (Fig. 11.6) is characterized by a decrease in the speed of the early diastolic occlusion of the anterior leaflet (EF tilt), a decrease in diastolic leaflet divergence (indicated by arrows), and a relative increase in the DC interval. Severe stenosis is manifested by a U-shaped unidirectional movement of the valves (Fig. 11, c).

Fig.11 Dynamics of the M-echogram of the mitral valve with the development of stenosis: a-norm; b-moderate stenosis; B-pronounced stenosis.

Unidirectional movement of the valves is a pathognomonic sign of rheumatic stenosis. Due to adhesions along the commissures, the anterior flap during opening pulls a smaller posterior flap, which also moves towards the sensor, and not away from it, as is normal (Fig. P., Fig. 12).

Figure: 12. A-M-echocardiogram in the II standard position of the transducer. Mitral stenosis. Unidirectional U-shaped movement of MK valves.

B-domed movement of PSMK on two-dimensional echocardiography (indicated by an arrow). 1 - the amplitude of the divergence of the valves of the MC; 2 - PSMK; 3 - ZSMK.

An essential echographic sign of mitral stenosis is an increase in the size of the left atrial cavity, measured in the III standard position of the transducer (more than 4-5 cm, the norm is 3-3.2 cm).

Features of valve changes in rheumatic lesions of the edges of the valves and commissures adhesions) determine the characteristic signs of stenosis on a two-dimensional echocardiogram.

The "domed" movement of the anterior flap is determined in longitudinal section from the parasternal approach. It consists in the fact that the valve body moves with a greater amplitude than its edge (Fig. 12, B). The mobility of the edge is limited by adhesions, while the valve body can remain intact for a long time. As a result, at the moment of diastolic valve opening, the body of the leaflet, filled with blood, "bulges" into the cavity of the left ventricle. Clinically, at this moment, the click of the opening of the mitral valve is heard. The origin of the sound phenomenon is similar to the clap of a wind-filled sail or an expanding parachute and is due to the fixation of the flap on both sides - a fibrous ring at the base and adhesions at the edge. With the progression of the defect, when the valve body also becomes rigid, the phenomenon is not detected.

Deformation of the mitral valve in the form of a "fish mouth" occurs in the later stages of the defect. This is a funnel-shaped valve due to adhesions of the leaflets along the commissures and shortening of the tendon. threads. The leaves of the rivet form a "head", and the thickened unidirectionally moving edges resemble the opening of a fish's mouth (Fig. 13, a).

Deformation of the valve in the form of a button loop - the mitral opening in the form of a gap formed by the compacted edges of the valves (pits 13.6).

a b

Figure: 13. Typical deformities of the valve cusps with mitral stenosis.

A two-dimensional echocardiogram in a section along the short axis at the level of the edges of the mitral valves at the time of their maximum opening allows measuring the area of \u200b\u200bthe mitral opening: moderate stenosis with an area of \u200b\u200b2.3-3.0 cm 2, pronounced - 1.7-2.2 cm 2, critical - 1.6 cm 2 or less. Patients with severe and critical stenosis are subject to surgical treatment.

In addition to the above direct signs of the defect, with the development of pulmonary hypertension and hypertrophy of the right heart, the corresponding changes are revealed on the one-dimensional and two-dimensional echocardiography.

So, the main signs of mitral stenosis on echocardiography are:

1. Unidirectional U-shaped movement of the flaps on a one-dimensional echogram.

2. Domed movement of the anterior flap on two-dimensional echocardiography.

3. Decrease in the amplitude of leaflet opening on one-dimensional and two-dimensional echocardiography, decrease in the area of \u200b\u200bthe mitral opening on two-dimensional echocardiography.

Dilation of the left atrium.

Insufficiency of the mitral valve

In comparison with mitral stenosis, echocardiography is of much lesser importance in the diagnosis of this defect, since only indirect signs are evaluated. A direct sign - a regurgitation regurgitation - is recorded by Doppler echocardiography.

Signs of mitral valve insufficiency (CMC) on univariate echocardiography
Increased systolic excursion of the posterior wall and interventricular septum, moderate dilatation of the left ventricular cavity (signs of LV volume overload).

3.Increase in the excursion of the posterior wall of the left atrium in the III position of the sensor (1 cm or more); moderate left atrial hypertrophy.

4. "Excessive" amplitude of the front sash opening (more than 2.7 cm).

5.Moderate decrease in the rate of early diastolic valve closure (EF inclination), which, however, does not reach the degree of decrease in this indicator during stenosis.

With a "chnsty" NMC, the movement of the lines remains multidirectional.

Signs of CCD on two-dimensional echocardiography also include the sometimes determined violation of the closure of the valves.

Mitral defect with predominance of stenosis.

EchoCG corresponds to that in mitral stenosis, however, changes in the left ventricle are also recorded (increased wall excursion, cavity dilatation), which is not observed in "pure" stenosis.

Mitral defect with a predominance of insufficiency.

In contrast to "pure" insufficiency, unidirectional diastolic movement of the valves is determined. In contrast to the predominance of stenosis, the rate of early diastolic closure of the anterior cusp (EF) is moderately reduced and its movement does not reach the U-shape (biphasicity remains - peak E followed by a "plateau").

Aortic stenosis

Echographic diagnosis of aortic defects is difficult due to the difficulties of visualizing both intact and deformed valves and is based mainly on indirect signs.

The main sign of aortic stenosis is a decrease in the systolic divergence of the aortic valve cusps, their deformation and thickening. The nature of the deformation of the valve depends on the etiology of the defect: in rheumatic stenosis (Fig. 14.6), adhesions are determined along the commissures with an opening in the center of the valve; with atherosclerotic lesion, the valve bodies are deformed, between which there are gaps (Fig. 14, c). Therefore, in atherosclerotic defect, despite a pronounced auscultatory picture, stenosis is usually not as significant as in rheumatism.

Fig 14. Scheme of deformation of the leaflets with stenosis of the aortic orifice, a-normal leaflets in diastole and systole; b-rheumatism atherosclerosis. PC-right coronary valve, PC-left coronary valve, NK-non-coronary valve.

An indirect sign of aortic stenosis is hypertrophy of the left ventricular myocardium without enlarging its cavity, as a result of pressure overload. Wall thickness is measured at I standard transducer position or 2D echocardiography.

Aortic valve insufficiency

With this defect, dilatation of the left ventricular cavity is determined as a result of volume overload and an increase in systolic excursion of its walls due to the volume of regurgitation. Direct flow of regurgitation can be recorded by Doppler echocardiography.

A stream of regurgitation, heading in diastole to the open anterior mitral valve (Fig. 15, a - indicated by an arrow), can cause its small-amplitude flutter (Fig. 15, b - indicated by an arrow).

Fig. 15. Insufficiency of the aortic valve: a-two-dimensional hogram, b-one-dimensional echocardiography in the II standard position of the transducer.

Occasionally, on a two-dimensional echogram, you can see the expansion of the aortic root, a violation of diastolic closure of the valves. On a one-dimensional echogram of the base of the aorta, this corresponds to the symptom of diastolic non-closure ("separation") of the cusps. In fig. 16 shows a diagram of the M-echogram of the base of the aorta in a patient with combined aortic defect. A sign of stenosis is a decrease in the amplitude of systolic valve divergence (1), a sign of insufficiency is a diastolic "separation" of the valves (2). The leaflets of the aortic valve are thickened, increased echogenicity.

Fig. 16 Scheme of M-echogram of the base of the aorta with combined aortic defect.

With a combination of stenosis and insufficiency, a mixed type of left ventricular hypertrophy is also determined - its cavity increases (as with insufficiency) and wall thickness (as with stenosis).

Hypertrophic cardiomyopathy

In the diagnosis of cardiomyopathies, echocardiography plays a leading role. Depending on the predominant localization of hypertrophy, several forms of hypertrophic cardiomyopathy (PSMP) are distinguished, some of which are shown in Fig. 17;

Asymmetric hypertrophy of the interventricular septum is spoken of if its thickness exceeds the thickness of the posterior wall by more than 1.3 times. The most common (almost 90% of all HCM) is the obstructive form, previously called "idiopathic hypertrophic subaortic stenosis" (Fig. 17, d). The thickness of the IVS in patients reaches 2-3 cm (the norm is 0.8 cm). Approaching the anterior cusp of the mitral valve or hypertrophied papillary muscles, it thereby creates obstruction of the outflow tract. The accelerated systolic blood flow in the obstruction area due to hydrodynamic forces (wing effect) pulls the anterior cusp to the hypertrophied IVS, exacerbating the stenosis of the outflow tract.

On a one-dimensional echogram in the P standard position, the following signs of obstructive HCM are revealed (Fig. 18):

1. An increase in the thickness of the IVS and a decrease in its systolic excursion due to fibrotic changes in the myocardium.

2. Anterior systolic deflection of the mitral valves and the convergence of the anterior valve with the interventricular septum.

Figure: 17. Forms of HCMP:

a-asymmetric interventricular septum;

b-concentric left ventricle;

in-apical (non-obstructive);

d-asymmetric basal sections of the IVS, the arrow indicates the zone of obstruction of the LV outflow tract.

Rie. 18. Echocardiogram of a ball with obstructive HCM. Increasing the thickness of the IVS. The arrow indicates the systolic deflection of the mitral cusps to the septum.

On the echogram of the base of the aorta in position III of the transducer, due to a decrease in cardiac output, a sredsystolic closure of the aortic valve leaflets can be observed, the form of movement of which in this case resembles the M-shaped movement of the mitral leaflets (Fig. 19).

Figure: 19. Sredsystolic cover of the aortic valve cusps (indicated by the arrow) in obstructive HCM.

Dilaticiotshm cardiomyopia

Dilated (congestive) cardiomyopathy (DCM) is characterized by diffuse myocardial damage with dilatation to her heart cavities and a sharp decrease his contractile function (Fig. 20).

Fig. 20. Echocardiography scheme of a patient with DCM: a - two-dimensional echocardiography, pronounced dilatation of all heart chambers; b- M-echocardiography-hypokinesis of IVS and ZSLZH, dilatation cavities of the RV and LV, an increase in the distance from the anterior MV valve (peak E) to the septum, characteristic movement of MV valves.

In addition to cavity dilatation, a decrease in myocardial contractility, including a drop in the ejection fraction, DCM is characterized by the formation of blood clots in the dilated cavities with frequent thromboembolytic complications.

Due to a decrease in the contractility of the left ventricular myocardium, LVEDD increases, which is manifested on echocardiography by the characteristic movement of the mitral cusps. The first type (Fig. 20, a) is characterized by high speeds of opening and closing of the valves (narrow peaks E and A), a low point F. This form is described as a "diamond-like" movement of the mitral valves, which is considered characteristic of left ventricular aneurysm against the background of coronary heart disease ( J. Burgess et al., 1973) (Fig. 21, a).

The second type, on the contrary, is characterized by a decrease in the rate of early diastolic occlusion of the anterior mitral cusp, expansion of both peaks with deformation of the presystolic valve due to an increase in the AS period and the appearance of a kind of "step" on this segment (Fig. 21, b - indicated by an arrow).

Figure: 21. Types of mitral valve leaflet movement in DCM.

The mitral valves are well located against the background of the dilated cavities of the left heart and move in antiphase ("fish mouth" according to H. Feigenbaum, 1976).

It is often difficult to distinguish DCM from dilatation of cardiac cavities in other diseases.

In the later stages of circulatory failure caused by coronary heart disease, dilatation of not only the left, but also the right parts of the heart can also be observed. However, in IHD, left ventricular hypertrophy predominates, the thickness of its walls is usually greater than normal. With DCM, as a rule, there is a diffuse lesion of all chambers of the heart, although there are cases with a predominant lesion of one of the ventricles. The wall thickness of the left ventricle in DCM usually does not exceed the norm. If there is a slight hypertrophy of the walls (no more than 1.2 cm), then visually the myocardium still looks "thinned" against the background of pronounced dilatation of the cavities. IHD is characterized by "mosaicism" of myocardial damage: affected hypokinetic areas coexist with intact ones, in which compensatory hyperkinesis is observed. In DCM, a diffuse process determines the total hypokineticity of the myocardium. The degree of hypokinesis of different areas can be different due to the different degree of their damage, but hyperkinetic zones in DCM are never detected.

An echocardiographic picture of dilatation of the heart cavities, similar to DCM, can be observed in severe myocarditis, as well as in alcoholic heart disease. To make a diagnosis in these cases, it is necessary to compare the echocardiographic data with the clinical picture of the disease and data from other studies.

List of references

1. Dvoryakovsky I.V., Chursin V.I., Safonov V.V. Ultrasound diagnostics in pediatrics. - L .: Medicine, 1987. -160 s.

2. Zaretsky V.V., Bobkov V.V., Olbinskaya L.I. Clinical echocardiography. - M .: Medicine, 1979. - 247 p.

3. Instrumental research methods of the cardiovascular system (Handbook) / Ed. T.S. Vinogradova. - M .: Medicine, 1986. - 416 p.

4. Interpretation of a two-dimensional echocardiogram / Yu.T. Malaya, I.I. Yabluchansky, Yu.G. Gorb and others - Kharkov: Vyshcha school, 1989.223 p.

5. Clinical ultrasound diagnostics: A guide for physicians: T.I / N.М. Mukharlyamov, Yu.N. Belenkov, O. Yu. Ltysov and others; ed. N.M. Mukharlyamov. - M .: Medicine, 1987. - 328 p.

6. Makolkin V.I. Acquired heart defects. - M .: Meditsina, 1986. - 256 p.

7. Mikhailov S.S. Clinical anatomy of the heart. - M .: Meditsina, 1987. - 288 p.

8. Moiseev B.C., Sumarokov A.V., Styazhkin V.Yu. Cardiomyopathy. - M .: Medipina, 1993. - 176 p.

9. Mukharlyamov N.M. Cardiomyopathy. - M .: Medicine, 1990. - 288 p.

10. Soloviev G.M. and others. Cardiac surgery in "chocardiographic research. - M .: Medicine, 1990 .-- 240 p.

11. Feigenbauii) H. Echogardiography. - Philadelphia: Lea and Febiger, 1976.-495p.

RHEOGRAPHY

Rheography - a bloodless method for studying blood circulation, based on the graphical registration of changes in the electrical resistance of living tissues during the passage of an electric current through them. An increase in vascular blood filling during systole leads to a decrease in the electrical resistance of the studied parts of the body.

Rheography reflects the change in the blood supply of the investigated area of \u200b\u200bthe body (organ) during the cardiac cycle and the rate of movement of blood in the vessels.

Arterial pressure - an integral indicator reflecting the result of the interaction of many factors, the most important of which are the systolic blood volume and the total resistance to blood flow of resistive vessels. Changes in the minute volume of blood (MVV) are involved in maintaining the known constancy of the mean pressure in the arterial system, which is determined by the relationship between the values \u200b\u200bof MVV and arterial peripheral vascular resistance. When there is coordination between flow and resistance, the mean pressure is a kind of physiological constant.

The main parameters of general hemodynamics include stroke and minute blood volume, mean systemic arterial pressure, total peripheral vascular resistance, arterial and venous pressure.

Average hemodynamic pressure in mm Hg

Due values \u200b\u200bRdr. depend on age and gender.

In assessing the functional state of the circulatory apparatus, the parameters of central hemodynamics are important: stroke (systolic) volume and cardiac output (minute blood volume). Stroke volume - the amount of blood that is thrown out by the heart with each contraction (the norm is in the range of 50-75 ml), cardiac output(minute blood volume) - the amount of blood ejected by the heart within 1 minute (the IOC norm is 3.5-8 liters of blood). The value of the IOC depends on gender, age, changes in ambient temperature and other factors.

One of the non-invasive methods for studying indicators of central hemodynamics is the method of tetrapolar chest rheography, which is considered the most convenient for practical use in the clinic.

Its main advantages, along with high reliability - the total error is not more than 15%, include the simplicity of registration and calculation of the main indicators, the possibility of repeated repeated studies, the total time spent does not exceed 15 minutes. Central hemodynamic indices determined by tetrapolar chest rheography and hemodynamic indices determined by invasive techniques (Fick's method, dye dilution technique, thermal dilution method) are highly correlated with each other.

Determination of the stroke volume of blood (SV) by the method of transthoracic tetrapolar rheography according to Kubitschek and Yu.T. Pushkar

Rheography - a bloodless method for studying blood circulation, which registers the electrical resistance (impedance or its active component) of living tissues, which changes with fluctuations in blood flow during the cardiac cycle at the moment an alternating current is passed through them. Abroad, the method of impedance cardiography or tetrapolar thoracic rheography is widely used to determine the hemodynamics of the left ventricle of the heart.

Kubitschek (1966) recorded the value of the body impedance according to the principle of four electrode measurement. In this case, two annular electrodes were placed on the neck and two on the chest, at the level of the xiphoid process. To implement the method, you need: RPG 2-02 rheoplethysmograph, a recorder with a recording width of 40-60 mm. It is better to record volumetric rheography and its first derivative in parallel with ECG recording (standard lead II) and PCG on the auscultatory canal.

Methodology

Calibrate the recording scale. The device provides two values \u200b\u200bof the calibration signal of the main rheogram, 0.1 and 0.5 cm. The amplitude of the calibration signal is 1 and 5 cm / s, respectively. The choice of the recording scale and the value of the calibration signal depends on the magnitude of the differential rheogram amplitude.

Electrode application diagram:

The interelectrode state L is measured with a measuring tape between the centers of potential electrodes No. 2 and No. 3 along the anterior surface of the chest.

The arrow indicator on the front panel of the device continuously shows the value of the base impedance (Z). With free breathing of the patient, we record 10-20 complexes.

The amplitude of the differentiated rheogram (Ad) in each of the complexes is defined as the distance (in ohms per second) from the baseline to the peak of the differentiated curve.

The mean ejection time (Ti) is defined in the same complexes as the distance between the beginning of the rapid rise of the differentiated curve to the lower incisure point or from the point corresponding to 15% of the height to the lower incisure point. Sometimes the beginning of this period can be determined by the beginning of the step on the curve, which corresponds to the end of the isometric contraction phase. When incisura is weakly expressed, the end of the expulsion period can be determined by the beginning of the II tone on the PCG with the addition of a constant lag time of the differentiated rheogram curve by 15-20

The values \u200b\u200bof the measured L, Z, Ad and Ti are transferred to the formula for determining the VR:

UO - stroke volume (ml),

K is the coefficient depending on the places where the electrodes are applied, on the type of device used (for this technique

K \u003d 0.9);

G - blood resistivity (ohm / cm) N \u003d 150;

L is the distance between the electrodes (cm);

Z is the interelectrode impedance;

Ad is the amplitude of the differentiated rheogram curve

Tu - expulsion time (sec).

Voltage Index - Time:

TT1 \u003d SADCHSSTp.

The method of tetrapolar chest rheography is widely used to determine the type of central hemodynamics in patients with essential hypertension. The distribution is usually carried out according to the value of the cardiac index (CI). So, patients with a cardiac index (CI) of more than M + 15% of its value in healthy individuals belong to the hyperkinetic type of hemodynamics, respectively, with a CI less than M-15% of its value in healthy individuals, patients are referred to a group with a hypokinetic type. With an SI value from M-15% to M + 15%, the state of blood circulation is considered eukinetic.

Currently, it is a generally accepted fact that hypertension is hemodynamically heterogeneous and requires a differentiated approach to treatment, depending on the type of blood circulation.

LITERATURE

1. Kassirsky I.A. Functional Diagnostics Handbook. - M .: Medicine, 1970.

2. Pushkar Yu.T., Bolypov V.M., Elizarova N.A. et al. Determination of cardiac output by tetrapolar chest rheography and its metrological capabilities // Cardiology. - 1977. - No. 7. - p.85-90.

3. Harrison T.R. Internal illnesses. - M .: Medicine, vol. 7, 1993.

PHONOCARDIOGRAPHY

Phonocardiography (PCG) is a method of graphic registration of heart sounds and murmurs and their diagnostic interpretation. PCG significantly complements auscultation, brings a lot of fundamentally new things to the study of heart sounds. It allows you to objectively assess the intensity and duration of heart sounds and murmurs. However, the correct interpretation is possible in combination with the clinical picture of the disease. The sensitivity of the human ear is more significant than that of the PCG sensor. The use of channels with different frequency characteristics makes it possible to selectively register the sounds of the heart, to determine the III and IV tones that are not audible during auscultation. Determining the shape of the noise makes it possible to establish its genesis and to resolve the issue of the wired character at different points of the heart. Simultaneous synchronous recording of PCG and ECG reveals a number of important regularities in the relationship between heart sounds and ECG.

Phonocardiographic research technique

PCG recording is carried out using a phonocardiograph, which consists of a microphone, an amplifier, a system of frequency filters and a recording device. A microphone located at various points in the heart region perceives sound vibrations and converts them into electrical ones. The latter are amplified and transmitted to a system of frequency filters, which separate one or another group of frequencies from all heart sounds and then pass them on to various recording channels, which makes it possible to selectively register low, middle and high frequencies.

The room in which the PCG is recorded must be isolated from noise. Usually PCG is recorded after 5 minutes of rest of the subject in the supine position. Preliminary auscultation and clinical data are decisive in the choice of the main and additional recording points, special techniques (recording in a lateral position, standing, after exercise, etc.). Usually, PCG is recorded when holding the breath while exhaling, and, if necessary, at the height of inspiration and when breathing. When using air-spaced microphones, complete silence is essential for recording. Vibration sensors - detect and record chest tremors, less sensitive, but more convenient in practical work.

Currently, the most common are two systems of frequency characteristics: Maass-Weber and Mannheimer. The Maass-Weber system is used in domestic phonocardiographs, German and Austrian. Mannheimer's system applied in Swedish vehicles

"Mingograf".

Frequency characteristics according to Maass-Weber:

The channel with the auditory characteristic has the greatest practical significance. The PCG recorded on this channel is compared in detail with the auscultatory data.

On channels with a low-frequency characteristic, III and IV tones are recorded, I and II tones are clearly visible when they are covered by noise on the auscultatory channel.

High-frequency noise is well recorded on the high-frequency channel. For practical work, it is good to use auscultatory, low-frequency and high-frequency characteristics.

The PCG should have the following special designations (in addition to the name of the subject, dates, etc.): ECG lead (usually II standard), frequency response of channels and recording points. All additional techniques are also noted: recording in the position on the left side, after physical exertion, while breathing, etc.

Normal phonocardiogram consists of vibrations of I, II and often III and IV heart sounds. The systolic and diastolic pause on the auscultatory canal corresponds to a straight, without hesitation line, which is called isoacoustic.

Scheme of a normal PCG. Q-I tone. a - the initial, muscle component of the I tone;

B - central, valve component of the I tone;

B - the final component of the I tone;

A - aortic component of the II tone;

P - pulmonary (pulmonalis) component of the II tone

With synchronous recording of PCG with an electrocardiogram, oscillations of the I tone are determined at the level of the S wave of the electrocardiogram, and the II tone - at the end of the T wave.

Normal I tone in the region of the apex of the heart and in the projection of the mitral valve, consists of three main groups of oscillations. Initial low-frequency, small amplitude oscillations - the muscle component of the I tone, due to the contraction of the ventricular muscles. The central part of the I tone, or as it is called - the main segment - more frequent oscillations, of large amplitude, are caused by the closure of the mitral and tricuspid valves. The final part of the I tone - oscillations of small amplitude associated with the opening of the valves of the aorta and pulmonary artery and vibrations of the walls of large vessels. The maximum amplitude of the I tone is determined by its central part. At the apex of the heart, it is IVa "2 times greater than the amplitude of the II tone.

The beginning of the central part of the I tone is separated from the beginning of the Q wave of the synchronously recorded ECG by 0.04-0.06 seconds. This interval is called the Q-I interval tone, the period of transformation or transformation. It corresponds to the time between the onset of ventricular excitation and the closure of the mitral valve. The greater the pressure in the left atrium, the greater the Q-I tone. Q-I tone cannot be an absolute sign of mitral stenosis, maybe - with myocardial infarction.

II tone on the base of the heart is 2 times or more more than I tone. In its composition, the first, large in amplitude, group of oscillations is often visible, corresponding to the closure of the aortic valves, the aortic component of the II tone. The second group of oscillations, 1.5-2 times smaller in amplitude, corresponds to the closure of the pulmonary artery valves - the pulmonary component of the II tone. The interval between the aortic and pulmonary components is 0.02-0.04 seconds. It is due to the physiological delay in the end of the right ventricular systole.

Normal III tone is often found in young people under 30 years old, asthenics and athletes. It is a weak and low-frequency sound and therefore is heard less often than it is recorded. III tone is well recorded on the low-frequency channel in the form of 2-3 rare oscillations of small amplitude, following 0.12-0.18 seconds after the II tone. The origin of the III tone is associated with muscle oscillations in the phase of rapid filling of the left ventricle (left ventricular III tone) and the right ventricle (right ventricular tone III).

Normal IV tone, atrial tone is determined less often than tone III in the same contingent. It is also a faint low-frequency sound that is usually not heard on au-scultation. It is determined on the low-frequency channel in the form of 1-2 rare, small amplitude oscillations located at the end of the P, synchronously recorded ECG. IV tone is due to atrial contraction. Total gallop - a 4 x -stact rhythm is heard (there are 3 and 4 tones), observed with tachycardia or bradycardia.

It is advisable to begin the analysis of PCG with a description of the tones and time intervals associated with them. Then noises are described. All additional techniques and their influence on tones and noises are at the end of the analysis. The conclusion can be accurate, differential diagnostic, presumptive.

Pathological changes in the phonocardiogram.

Pathology of tones.

Weakening of the I tone - a decrease in its amplitude is of independent importance in the area of \u200b\u200bthe mitral and tricuspid valves. It is mainly determined in comparison with the amplitude of the II tone. The weakening of the I tone is based on the following reasons: destruction of atrioventricular valves, mainly mitral, limitation of valve mobility, calcification, decreased contractile function of the myocardium, with myocarditis, obesity, myxedema, mitral valve insufficiency.

Amplification of I tone occurs with fibrosis of the atrioventricular valves with the preservation of their mobility, with a rapid increase in intraventricular pressure. With a shortening of the P-Q I interval, the tone increases, and with lengthening, it decreases. It is observed with tachycardia (hyperthyroidism, anemia) and often with mitral stenosis. With a complete atrioventricular block, the greatest amplitude of the I tone ("cannon" tone according to ND Strazhenko) is observed when the P wave is directly adjacent to the QRS complex.

Splitting I tone up to 0.03-0.04 seconds with an increase in both components occurs in mitral-tricuspid stenosis due to the simultaneous closure of the mitral and tricuspid valves. It also occurs with bundle branch block as a result of asynchronism in the contraction of the ventricles -

Attenuation of II tone has an independent meaning in the aorta, where it is due to the destruction of the aortic valves or a sharp restriction of their mobility. A decrease in pressure in the aorta and pulmonary artery also leads to a weakening of the II tone.

Gain II tone on the aorta or on the pulmonary artery is associated with an increase in blood pressure in these vessels, compaction of the stroma of the valves (essential hypertension, symptomatic hypertension, hypertension of the pulmonary circulation, atherosclerotic changes).

Splitting II tone characterized by a stable delay of the pulmonary component, independent of the phases of breathing, - "fixed" splitting of the II tone in the terminology of foreign authors. It occurs when the phase of blood expulsion from the right ventricle is lengthened, which leads to a later closure of the pulmonary artery valves. This occurs when there is an obstruction to the outflow of blood from the right ventricle - stenosis of the pulmonary artery, when the right heart is overfilled with blood. The pulmonary component of the II tone increases, becomes equal to the aortic and even exceeds it with increased blood supply of the pulmonary circulation and decreases or completely disappears with low blood supply of the pulmonary circulation. Pathological splitting of the II tone is also noted with blockade of the right bundle branch. The development of severe pulmonary hypertension with changes in the vessels of the pulmonary circulation leads to a shortening of the phase of expulsion of blood from the right ventricle, to an earlier closure of the pulmonary artery valves and, consequently, to a decrease in the degree of splitting of the II tone. Then there is a fusion of the large component with the aortic, as a result of which a large unsplit II tone is determined, which is most pronounced in the area of \u200b\u200bthe pulmonary artery, which is determined by auscultation as sharply accentuated. This II tone is a sign of severe pulmonary hypertension.

Splitting of the II tone with a delay in the aortic component is rare and is called "paradoxical". It is caused by a sharp slowdown in the phase of expulsion of blood from the left ventricle with stenosis of the aortic orifice or subclanic stenosis, as well as with blockade of the left bundle branch.

Pathological III tone - large amplitude, fixed on the auscultatory canal and well audible during auscultation, associated with increased diastolic blood flow to the ventricles or with a sharp weakening of myocardial tone (myocardial infarction). The appearance of a pathological III tone determines a three-membered rhythm - a pro-diastolic gallop.

Pathological IV tone also characterized by an increase in amplitude and fixation on the auscultatory canal. Most often occurs when the right atrium is overloaded with congenital heart defects. The appearance of a pathological atrial tone determines the presystolic form of the gallop rhythm.

A low-frequency PCG recording is used to characterize the tones.

Sometimes a click or a late systolic click is recorded on the PCG in systole. It is better heard during exhalation at the apex and at Botkin's point. Click - on the PCG a narrow group of oscillations recorded on the mid-frequency or high-frequency channel of the PCG, at the beginning or at the end of systole and associated with mitral valve prolapse.

In diastole, an extraton is recorded - a click of the opening of the mitral valve (open snep "O.S.") occurs in mitral stenosis. OS - consists of 2-5 vibrations, with a duration of 0.02-0.05 ", it is necessarily visible on the high-frequency channel, at a distance of 0.03-0.11" from the beginning of the II tone. The higher the pressure in the left atrium, the shorter the distance II tone - 08.

With stenosis of a 3-leaflet valve, the tone of the tricuspid valve opening is analogous to the click of the mitral valve opening. Short and sparse, it is better heard to the right and left of the xiphoid process, in the fourth intercostal space to the left of the sternum. It is better heard on exhalation, it is separated from the II tone at a distance of 0.06 "- 0.08".

Medium and high frequency channels are used to analyze the noise pattern.

Noise characteristic:

1.relationship to the phases of the cardiac cycle (systolic and diastolic);

2. duration and shape of noise;

3. the temporal ratio of noise and tones;

4.frequency response

5. in terms of duration and timing. I. Systolic: a) protosystolic;

B) mesosystolic;

C) late systolic;

D) holo or pansystolic.

Scheme of changes in tones and murmurs with acquired heart defects.

OS m - mitral valve opening tone;

OS t - the tone of the tricuenidal valve opening;

I m - mitral component of I tone;

I t - tricuspid component of the I tone;

1 - mitral valve insufficiency;

2 - mitral stenosis;

3 - mitral stenosis and mitral valve insufficiency;

4 - insufficiency of the aortic valve;

5 - aortic stenosis;

6 - aortic stenosis and aortic valve insufficiency;

7 - insufficiency of the tricuspid valve;

8 - tricuspid stenosis;

9 - tricuspid stenosis and tricuspid valve insufficiency.

Functional systolic murmurs - low-amplitude, low-frequency, spaced from I tone by 0.05 ", less than 0.5" systole duration, usually have a growing character or have a diamond shape. For differential diagnosis, physical activity is used, the Valsalva test, conductivity is taken into account, the test with amyl nitrite is an increase in functional noise.

LITERATURE

Kassirsky I.A. Functional Diagnostics Handbook. - M .: Medicine, 1970. Harrison T.R. Internal illnesses. - M .: Medicine,

Chapter 8. Mitral valve

General issues

Normal heart valves are so thin and mobile that they cannot be visualized with most diagnostic methods. Echocardiography, which records the differences in acoustic characteristics between connective tissue and blood, allows you to see the heart valves in detail. All existing types of echocardiography are used to study the valvular apparatus of the heart.

The advantage of M-modal echocardiography is its high resolution; the disadvantage is the limited observation area. The main field of application of M-modal echocardiography is the registration of delicate valve movements, such as diastolic vibration of the anterior mitral valve leaflet in aortic regurgitation or mean systolic aortic valve closure in hypertrophic cardiomyopathy.

Two-dimensional echocardiography provides a large observation area, but the larger this area, the lower the resolution of the method; An important advantage of two-dimensional echocardiography is that it can determine the prevalence of valvular lesions, for example, in aortic valve hardening.

Doppler echocardiography allows you to qualitatively and quantitatively assess blood flow through each of the heart valves. The main disadvantage of the method is the need to direct the ultrasonic beam strictly along the flow in order to avoid distortion of the research results. However, the possibilities offered by Doppler echocardiography, such as assessing the hemodynamic significance of aortic stenosis and calculating pulmonary artery pressure, are almost revolutionary advances that can serve as an example of what non-invasive techniques can provide.

With the widespread use of echocardiography, more and more patients undergo surgical correction of valvular heart defects without prior cardiac catheterization. You can confidently rely on the results of echocardiographic assessment of the severity of the defect, which led to severe hemodynamic disturbances. Only in two cases is an echocardiographic study insufficient: 1) if there is a contradiction between the clinical data and the results of an echocardiographic study; 2) if, when undoubtedly necessary surgical correction the defect is required to find out other issues, most often - the presence or absence of coronary artery pathology.

Normal mitral valve

Historically, it was the mitral valve that was the first structure recognized by ultrasound examination of the heart. The orientation of the broad surface of the anterior mitral leaflet in relation to the chest wall makes it an ideal target for ultrasound reflection. The anterior cusp of the mitral valve is very mobile, the ratio of the length of its edge to the base is large: this allows a good examination of its structure and movement both in M-modal and two-dimensional studies.

Echocardiography allows you to diagnose almost any pathology of the mitral valve; in particular, mitral valve prolapse. Our knowledge of the widespread prevalence of this pathology in the population is a consequence of the widespread introduction of echocardiography into clinical practice over the past 15 years.

A complete echocardiographic examination should include M-modal, two-dimensional, and Doppler (pulsed, continuous-wave and color scanning) examinations of the mitral valve. Doppler methods are very informative for the diagnosis of mitral valve pathology and for the quantitative assessment of transmitral blood flow. The mitral valve is examined from several approaches: parasternal, apical and, less often, from subcostal.

An M-modal study shows that the movement of the normal mitral valve reflects all phases of diastolic filling of the left ventricle (Fig. 2.3). The early maximum opening of the mitral valve (movement of the anterior cusp towards the interventricular septum) corresponds to the early, passive, diastolic filling of the left ventricle; the second, smaller, peak corresponds to atrial systole. Between these peaks, the mitral valve almost closes (diastasis period) due to equalization of pressures in the ventricle and atrium. During atrial systole, the valve opens again, so that the shape of the movement of the anterior valve leaflet resembles the letter M, and the movement of the posterior leaflet mirrors the movement of the front leaflet, yielding in amplitude. Closure of the mitral valve at the end of diastole occurs as a result of slowing blood flow from the atrium and the onset of isometric contraction of the left ventricle.

2D views of the mitral valve depend on the position from which the examination is performed. Thus, in parasternal examination along the short axis, the mitral valve is visible as an ovoid structure, and when examined along the long axis, it resembles opening and closing doors, the front of which is larger than the rear. In fig. 2.1 shows an image of the mitral valve when examined along the parasternal long axis of the left ventricle, in Fig. 2.11 - when examining in a four-chamber position from an apical approach. In general, a normal mitral valve should look like a movable bicuspid structure that opens so as not to interfere with filling of the ventricle, reliably closes into systole without falling into the left atrium. A normally closing mitral valve moves into systole with the base of the heart and is involved in pumping blood into the left atrium. Other anatomical structures associated with the mitral valve are chords, papillary muscles, and the left atrioventricular ring.

A Doppler study of a normal mitral valve reveals that the blood flow velocity through it can also be represented graphically with the letter M. In other words, blood flow has a maximum speed in early diastole, then almost stops and accelerates again during atrial systole. It is most often possible to direct the ultrasound beam parallel to the blood flow through the mitral valve from the apical approach, which is used for Doppler examination of the mitral valve. Fine maximum speed transmitral blood flow is slightly less than 1 m / s (Fig. 3.4C).

Mitral stenosis

Mitral stenosis was the first disease recognized by echocardiography. In the vast majority of cases, the cause of mitral stenosis is rheumatism. Anatomical manifestations of mitral stenosis consist in partial fusion of the commissures between the anterior and posterior cusps and changes in the subvalvular apparatus - shortening of the chords. As a result, the area of \u200b\u200bthe mitral opening decreases, which leads to obstruction of diastolic blood flow from the left atrium to the ventricle. With mitral stenosis, due to incomplete opening of the valve, the trajectory of its rapid two-phase movement changes. Echocardiography allows not only to diagnose mitral stenosis, but also to accurately calculate the area of \u200b\u200bthe mitral orifice, so that the patient can be referred for surgery or balloon valvuloplasty without prior cardiac catheterization. The severity of mitral stenosis can be quantified using three echocardiographic techniques.

1. M-modal study. In the M-modal study of a patient with mitral stenosis, changes in the form of movement of the mitral valve are visible, which are expressed in an increase in the time of its early closure (Fig. 8.1). One can see the unidirectional diastolic movement of the tips of the mitral valve leaflets. The slope of the early diastolic occlusion of the anterior mitral cusp (EF segment of the M-modal mitral valve image) allows mitral stenosis to be recognized. An inclination of the EF segment of less than 10 mm / s (normally\u003e 60 mm / s) while holding the breath indicates severe mitral stenosis. Currently, this feature is practically not used, since it is the least reliable of the methods for determining the severity of mitral stenosis.

Figure 8.1. Critical mitral stenosis, M-modal study: unidirectional diastolic movement of the tips of the mitral valve leaflets; the inclination of the diastolic covering of the anterior cusp of the mitral valve is almost absent. RV - right ventricle, LV - left ventricle, PE - small pericardial effusion, aML - anterior mitral valve leaflet, pML - posterior mitral valve leaflet.

2. Two-dimensional research. Normally, when examined from the parasternal position of the long axis of the left ventricle, the anterior mitral valve leaflet during the maximum opening of the valve in diastole looks like a continuation of the posterior wall of the aorta, whereas in mitral stenosis it has a dome-shaped rounding towards the posterior leaflet. The shortest distance between the valves is the distance between their tips (Fig. 8.2). The dome-shaped curvature of the sash occurs due to an increase in pressure on its unsecured part; an analogy is the inflating of the sail. The area of \u200b\u200bthe mitral opening should be measured in the parasternal position of the short axis of the left ventricle strictly at the level of the leaflet tips (Fig. 8.3). This planimetric method for assessing the severity of mitral stenosis is significantly more reliable than the M-modal one.

Figure 8.2. Mitral stenosis: parasternal position of the long axis of the left ventricle, diastole. Domed bulging of the anterior mitral cusp (arrow). LA - left atrium, RV - right ventricle, LV - left ventricle, Ao - ascending aorta.

Figure 8.3. Mitral stenosis: parasternal position of the short axis of the left ventricle at the level of the mitral valve, diastole. Planimetric measurement of the mitral orifice area. RV - right ventricle (dilated), PE - a small amount of fluid in the pericardial cavity, MVA - mitral orifice area.

3. Doppler studies of transmitral blood flow (Fig. 8.4). With mitral stenosis, the maximum speed of early transmitral blood flow is increased to 1.6-2.0 m / s (the norm is up to 1 m / s). The maximum velocity is used to calculate the maximum diastolic pressure gradient between the atrium and the ventricle. To calculate the area of \u200b\u200bthe mitral orifice, the changes in this gradient are investigated: the half-time of the pressure gradient (T 1/2) is calculated, that is, the time during which the maximum gradient is halved. Since the pressure gradient is proportional to the square of the blood flow velocity (? P \u003d 4V 2), its half-decay time is equivalent to the time during which the maximum velocity decreases by? 2 (about 1.4) times. Hatle has empirically established that a pressure gradient half-time of 220 ms corresponds to a mitral orifice area of \u200b\u200b1 cm 2. Mitral orifice area (MVA) is measured in continuous wave mode from the apical approach using the formula: [Mitral orifice area (MVA, cm 2)] \u003d 220 / T 1/2.

Figure 8.4. Two cases of mitral stenosis: critical stenosis ( AND) and mild stenosis ( IN). Continuous wave Doppler examination, apical approach. Measurement of the mitral orifice area is based on the calculation of the half-decay time of the transmitral pressure gradient. The faster the rate of diastolic transmitral blood flow decreases with mitral stenosis, the larger the area of \u200b\u200bthe mitral opening. MVA is the area of \u200b\u200bthe mitral foramen.

Of all the three named methods, Doppler is the most reliable and should be preferred over M-modal and two-dimensional determination of the mitral orifice area. Table 10 is a list of measurements that need to be made in a Doppler examination of a patient with mitral stenosis.

Table 10.Parameters determined by Doppler examination of a patient with mitral stenosis

Color Doppler scanning allows you to see the area of \u200b\u200baccelerated blood flow at the site of narrowing of the mitral opening (the so-called vena contracta) and the direction of diastolic flows in the left ventricle. Color scanning allows for a more accurate spatial orientation of the stenotic jet, which helps to align the ultrasound beam parallel to the flow during the continuous wave examination with an eccentric jet direction.

It should be remembered that the half-time of the pressure gradient depends not only on the area of \u200b\u200bthe mitral opening, but also on cardiac output, pressure in the left atrium, and compliance of the left ventricle. The use of the Doppler method for measuring the area of \u200b\u200bthe mitral opening can lead to an underestimation of the severity of mitral stenosis in cardiomyopathy or severe aortic regurgitation, since these conditions are accompanied by a rapid increase in left ventricular diastolic pressure and, consequently, a rapid drop in the velocity of the transmitral blood flow. An incorrect result of measuring the area of \u200b\u200bthe mitral opening can be given by atrioventricular block of the 1st degree, atrial fibrillation with a high frequency of ventricular contractions or its pronounced variability. Sometimes it is difficult to decide which complex of diastolic transmitral blood flow to take as a basis for calculating the area of \u200b\u200bthe mitral opening in atrial fibrillation. We recommend using the beats corresponding to the longest RR interval (equal to at least 1000 ms) on the monitor lead of the electrocardiogram. Another source of errors in measuring the area of \u200b\u200bthe mitral opening can be the nonlinearity of the decrease in the velocity of diastolic transmitral blood flow (Fig. 8.5). In this case, too, it is difficult to decide which part of the Doppler spectrum to select for measurements. Hatle recommends measuring the portion of the spectrum corresponding to the longer half-decay time of the pressure gradient (and thus the smaller mitral orifice area).

Figure 8.5. Mitral stenosis: continuous wave Doppler examination from the apical approach. The nonlinearity of the descending part of the Doppler spectrum of the stenotic jet is a possible source of errors in the Doppler determination of the mitral orifice area. The figure shows possible options for calculating the area of \u200b\u200bthe mitral opening; during cardiac catheterization, the area of \u200b\u200bthe mitral opening was 0.7 cm 2.

Indirect methods for assessing the severity of mitral stenosis include determining the degree of shortening of the chords, the severity of calcification of the mitral valve leaflets, the degree of enlargement of the left atrium, changes in the volume of the left ventricle (i.e., the degree of its underfilling) and examination of the right heart. By studying the size of the right heart and the pressure in the pulmonary artery (along the tricuspid regurgitation gradient), it is possible in each case to judge the consequences of mitral stenosis and the risk of surgery.

Non-rheumatic left ventricular obstruction

Calcification of the mitral annulus is a common echocardiographic finding. This is a degenerative process, most often associated with the advanced age of the patient. Often, calcification of the mitral ring is found in hypertrophic cardiomyopathy, in kidney disease. Calcification of the mitral annulus can cause a violation of atrioventricular conduction. Usually, calcification of the mitral annulus is not accompanied by hemodynamically significant mitral insufficiency or stenosis (Fig. 8.6), but in rare cases, calcium infiltration of the entire mitral valve apparatus is so pronounced that it leads to obstruction of the mitral orifice requiring surgical intervention. Doppler measurement of the mitral foramen area is the best way to identify and assess the severity of this rare complication of frequent pathology.

Figure 8.6.Calcification of the mitral annulus: the apical position of the four-chambered heart. RV - right ventricle, LV - left ventricle, MAC - mitral foramen calcification.

Congenital malformations with left ventricular outflow tract obstruction are rare in adults. These malformations include the parachute mitral valve (the only papillary muscle), the supravalvular mitral ring, and the tri-atrial heart (Fig. 8.7). Left atrial myxoma may prevent normal filling of the left ventricle. Carcinoid syndrome can develop in patients with metabolically active serotonin-producing tumors. This is a rare syndrome, and it is most often found in isolated lesions of the right heart of the heart (Fig.10.3). Of the 18 cases of this disease observed at the UCSF Echocardiography Laboratory, only two had left heart disease, presumably associated with bronchogenic cancer.

Figure 8.7. Cor triatriatum (three-atrial heart): The membrane that divides the left atrium into the proximal and distal chambers. Transesophageal echocardiographic examination in the transverse plane at the level of the heart base. Ao - ascending aorta, LAA - left atrial appendage, dLA - distal left atrial chamber, pLA - proximal left atrial chamber.

Mitral insufficiency

Stenosing lesions of the mitral valve alter its diastolic movement and can be easily recognized using M-modal and two-dimensional echocardiography. Mitral valve pathology with mitral regurgitation is often subtle and more difficult to diagnose. This is because the movements of the mitral valve during systole are minimal, but if even a small part of the valve does not function correctly, then pronounced mitral regurgitation occurs. Nevertheless, in a large number of cases of mitral regurgitation, its anatomical causes can still be identified using echocardiography.

The data given in table. 11 give an idea of \u200b\u200bthe main etiological causes of mitral regurgitation. This table is based on results from 1976-81. work in which the data of echocardiography, angiography and surgical treatment in 173 patients with mitral regurgitation were studied. Note that mitral valve prolapse appears to be the leading cause of mitral regurgitation.

Table 11.Etiology of mitral regurgitation

	Number of cases	Share of the total,%
Mitral valve prolapse	56	32,3
Rheumatism	40	23,1
Myocardial diseases (LV dilatation - 11%, hypertrophy - 6%)	30	17,3
Coronary heart disease	27	15,6
Bacterial endocarditis	11	6,3
Congenital heart defects	9	5,2
Adapted from Delaye J, Beaune J, Gayet JL et al. Current etiology of organic mitral insufficiency in adults. Arch Mal Coeur 76: 1072.1983

Doppler examination plays a very important role in the diagnosis of mitral insufficiency of any severity. The best method to look for mitral regurgitation is color Doppler scanning, as it is highly sensitive and does not take much time. Color Doppler scans provide real-time information on mitral regurgitation. Although an idea of \u200b\u200bthe direction and depth of penetration of the regurgitant stream can be obtained in the pulsed Doppler mode, color scanning is more reliable and technically simpler, especially in eccentric regurgitation. From the apical approach, mitral regurgitation looks like a light blue flame appearing in systole, directed towards the left atrium (Fig. 17.9). To register mitral insufficiency and determine the degree of its severity, the method of color scanning in sensitivity approaches the radiopaque ventriculography.

About 40-60% of healthy people have mitral regurgitation, which is caused by insufficiency of the postero-medial commissure of the mitral valve, but this regurgitation is not significantly pronounced. In this case, the regurgitant stream penetrates into the left atrial cavity by less than 2 cm.If the flow enters the left atrial cavity for more than half of its length, reaches its posterior wall, enters the left atrial appendage or the pulmonary veins, then this indicates severe mitral failure. In fig. On 17.9, 17.10, 17.11 mitral regurgitation of small, medium and high severity is presented.

It should be borne in mind that when examining a dilated left atrium, there is a loss of sensitivity of color scanning at great depths, and the severity of mitral regurgitation can be underestimated. The width of the formed stream at the level of the valve and its divergence on the atrial side of the valve also make it possible to judge the degree of mitral regurgitation.

As a rule, if mitral regurgitation is not detected by color scanning, then other Doppler methods are no longer used to search for it. However, with poor cardiac imaging, color scans may not be sensitive enough. In cases where transthoracic echocardiography is technically difficult, and accurate knowledge of the degree of mitral regurgitation is necessary, transesophageal echocardiography is indicated. The circumstances that complicate the assessment of the degree of mitral regurgitation during transthoracic examination include calcification of the mitral annulus and mitral valve leaflets, as well as the presence of a mechanical prosthesis in the mitral position.

In fig. 17.2 shows an image of mild mitral regurgitation obtained during transesophageal color Doppler examination of a patient with a dilated left atrium. Note that the choice of the correct amplification led to a clear visualization of "spontaneous contrasting" of the left atrium, which indicates a technically correct study and excludes underestimation of the degree of mitral regurgitation. In fig. 17.13 shows minor mitral regurgitation typical of a normally functioning prosthetic mitral valve. Figure: 17.14 illustrates high-grade paravalvular regurgitation with a disc prosthesis in the mitral position. In fig. 17:15 it is seen how the stream of mitral regurgitation enters the gigantic size of the left atrial appendage.

If it is impossible to conduct a color scan, the degree of mitral regurgitation is determined using a Doppler study in a pulsed mode. The control volume is first set over the place where the mitral leaflets are closed in the left atrium. We recommend looking for mitral regurgitation in multiple positions, as it can be eccentric. Thorough Doppler imaging with modern sensitive equipment often reveals early systolic signals of low intensity, which correspond to the so-called "functional" mitral regurgitation. The low density of the Doppler spectrum when such regurgitation is detected indicates a small number of red blood cells participating in it. It is possible that the detection of such a slight regurgitation is associated with the registration of the movement of a small number of red blood cells remaining at the end of diastole on the eve of the mitral opening.

With hemodynamically significant mitral regurgitation, the intensity of the Doppler spectrum is significantly higher. However, due to the high velocity of the stream of mitral regurgitation, due to the large pressure gradient in the systole between the ventricle and the atrium, a distortion of the Doppler spectrum occurs in a pulsed Doppler study and in color scanning. The larger the volume of regurgitant blood, the denser the Doppler spectrum. Doppler signal mapping in a pulsed mode consists in tracking the regurgitant stream, starting from the place of closure of the mitral valve leaflets and further when the control volume moves towards the superior and lateral walls of the left atrium. This method of determining the degree of mitral regurgitation is used in cases where color scanning cannot be performed. The denser the spectrum of mitral regurgitation and the deeper into the left atrium it penetrates, the heavier it is. With the help of continuous wave examination, the maximum rate of mitral regurgitation can be accurately measured. However, this parameter is of little importance for assessing the severity of mitral regurgitation, since the maximum velocity reflects a large systolic pressure gradient between the left ventricle and the atrium, which is large both in norm and in pathology. Only with very severe mitral regurgitation does the pressure in the left atrium during systole reach such a value that the maximum regurgitation rate decreases.

To assess the severity of mitral regurgitation, you can use two-dimensional and Doppler methods for calculating the volume of regurgitant blood. In mitral insufficiency, the volume of blood that flows from the left ventricle into the aorta is less than the volume flowing into the ventricle during diastole. The difference between the values \u200b\u200bof stroke volume calculated by planimetric (end-diastolic minus end-systolic volume) and Doppler (product of the linear integral of blood flow velocity in the outflow tract of the left ventricle and the area of \u200b\u200bthe outflow tract) by methods is equal to the volume of regurgitating blood for each cardiac cycle. However, these calculations give a large error, since the planimetric measurements underestimate and the Doppler measurements overestimate the values \u200b\u200bof the stroke volume.

The formula for calculating the regurgitant volume fraction to assess the severity of mitral regurgitation is rarely used due to the high probability of errors. We nevertheless consider it necessary to give a method for calculating the fraction of the regurgitating volume (Table 12). Note that the condition for the applicability of the above formula is the absence of aortic valve pathology.

Table 12.Calculation of the fraction of regurgitant volume (RF) in mitral regurgitation

Positions and measurements

1. Apical 2-chamber position

2. Apical 4-chamber position

3. Opening of the aortic valve in the M-modal mode parasternally

4. Aortic blood flow from the apical approach in continuous wave mode

Design parameters

1. The area of \u200b\u200bthe aortic valve opening (AVA) - according to the diameter of its opening

2. Fraction of regurgitant volume (RF):

a) Stroke volume (SV p) according to Simpson

b) Doppler calculation of the stroke volume (SV d): SV d \u003d AVA? VTI, where VTI is the integral of the linear velocity of blood flow through the aortic valve

c) RF \u003d (SV p - SV d) / SV p

Indirect indicators of the severity of mitral insufficiency can be the size of the left atrium and ventricle. Severe mitral regurgitation is accompanied by dilatation of the left ventricle due to its volume overload. In addition, the pressure in the pulmonary artery rises, which can be estimated by measuring the flow velocity of the tricuspid regurgitation.

Rheumatic lesion of the mitral valve, as a rule, is expressed in its combined lesion. At the same time, despite the presence of anatomical signs of rheumatic mitral stenosis, hemodynamically significant obstruction of the left ventricular delivery tract is often not detected. When echocardiographic examination in M-modal and two-dimensional mode, even in the absence of changes in hemodynamics, signs of rheumatic lesions are revealed in the form of thickening and sclerosis of the leaflets, diastolic dome-shaped rounding of the anterior leaflet of the mitral valve. In the differential diagnosis of combined mitral valve lesion and "pure" mitral insufficiency, Doppler study plays the main role.

Mitral valve prolapse was first described as a syndrome involving clinical, auscultatory, and electrocardiographic changes in the mid-1960s. Then it was shown that the mid-systolic click and murmur correlate with the sagging of the mitral valve leaflets detected during angiography. The realization of the importance of this syndrome occurred in the early 70s, when it turned out that mitral valve prolapse has vivid echocardiographic manifestations. And it was thanks to echocardiography that it became clear how common this syndrome is in the population. Two-dimensional echocardiography is of the greatest importance in its diagnosis; Doppler studies complement it, allowing to detect late systolic mitral regurgitation and determine the degree of its severity.

M-modal echocardiography gives about 40% false-negative results when cardiac auscultation is taken as the diagnostic standard. Perhaps such a low sensitivity of the method is associated with chest deformities; it has been shown that up to 75% of patients with mitral valve prolapse have radiographic signs of bone deformities of the chest. Such deformations (for example, pectus excavatum) can greatly complicate the conduct of an M-modal study. However, it is not interference with echocardiography that is much more important, but the fact that skeletal changes indicate a systemic nature of connective tissue damage in mitral valve prolapse.

Diagnosis of mitral valve prolapse requires a mandatory combination of M-modal and two-dimensional echocardiography (Fig. 8.8, 8.9). A two-dimensional study allows you to examine the entire mitral valve leaflets and find the place of their closure. The apparent sagging of the valves in the left atrium does not pose diagnostic problems. If the leaflets (or one leaflet) only reach the atrioventricular tubercle, and not further, this can cause diagnostic difficulties.

Figure 8.8. Mitral valve prolapse: parasternal position of the long axis of the left ventricle, systole. Both cusps of the mitral valve prolapse (arrows). It is clearly seen that the anterior cusp has an excessive length that does not correspond to the size of the ventricle. LA - left atrium, LV - left ventricle, Ao - ascending aorta.

Figure 8.9. Late systolic prolapse of the anterior mitral valve leaflet, M - modal study. Prolapse of the anterior mitral cusp occurs at the end of systole (arrows).

A number of researchers believe that since the mitral ring has a saddle shape, and its upper points are located in front and behind, the valve displacement above the level of the mitral ring should be recorded only from those positions that cross the valve in the anteroposterior direction. These positions are the parasternal long axis of the left ventricle and the apical bicameral position. The addition of Doppler to M-modal and 2D was found to give a specificity of 93% for mitral valve prolapse. It seems, however, that the diagnosis of mitral valve prolapse cannot be based on Doppler studies. Given the prevalence of mild mitral regurgitation, this can lead to overdiagnosis of mitral valve prolapse. In our opinion, only the detection of late systolic mitral regurgitation can be considered a diagnostically important result of a Doppler study for recognizing mitral valve prolapse.

In addition to changes in the trajectory of valve movement, mitral valve prolapse is also accompanied by their thickening and deformation. Usually the tips of the valves are most affected and look like a pin head with a matte surface. The thickening of the valves sometimes extends to the chords. Such changes in the valve apparatus are called myxomatous degeneration (degeneration). The more the valve is deformed, the higher the chances of detecting a thickening of the endocardium of the interventricular septum in the place where it comes in contact with the excessively mobile anterior cusp (a similar local thickening of the endocardium of the interventricular septum is often found in hypertrophic cardiomyopathy). The more deformed the leaflets, the higher the likelihood of clinical manifestations and complications of mitral valve prolapse: chest pain, heart rhythm disturbances, bacterial endocarditis, embolism and chord rupture. In extreme cases, it is often impossible to distinguish prolapse from threshing leaflets and massive vegetations on the mitral valve (Fig. 8.10).

Figure 8.10. Myxomatous degeneration of the mitral valve, complicated by rupture of the chords and threshing posterior cusp of the mitral valve. Parasternal position of the long axis of the left ventricle, diastole ( AND) and systole ( IN). RV - right ventricle, LV - left ventricle, LA - left atrium.

Bacterial endocarditis has become much better diagnosed with the advent of echocardiography; the range of information about this disease has expanded. The direct and main sign of bacterial endocarditis in case of damage to any valve is the detection of vegetation. Violating the integrity of the leaflets or chords, vegetation prevents the valve from closing completely and leads to mitral insufficiency. Vegetations look like formations on valves, usually very mobile. Detection of lesions on valves in the presence of clinical suspicion of bacterial endocarditis almost always allows a correct diagnosis. However, for fresh vegetation, one can take myxomatous degeneration of the mitral valve, and old, "healed" vegetations, and a torn leaf or chord. On the other hand, if an echocardiographic study is performed shortly after the first clinical symptoms of bacterial endocarditis appear, vegetation may not be detected. Vegetations of small sizes may remain undetected by echocardiographic examination due to insufficient resolution of the apparatus, low signal-to-noise ratio, or due to insufficient qualifications or inattention of the echocardiographer. In the UCSF Echocardiography Laboratory, vegetation with a diameter of less than 5 mm has almost never been recognized by M-modal examination. A two-dimensional study in such cases usually revealed some changes in valves, but not vegetation. At the same time, M-modal examination of patients with suspected bacterial endocarditis has the advantage over two-dimensional examination, which allows detecting a violation of the integrity of the valve, since it records high-frequency systolic vibrations, which are invisible in a two-dimensional examination due to the lower temporal resolution.

It should be borne in mind that bacterial endocarditis usually affects the initially altered valves; therefore, it is almost impossible to recognize vegetation of small sizes (less than 5 mm) against the background of existing valve changes. Myxomatous degeneration of the mitral valve with rupture of the chords is a good example of possible diagnostic difficulties (Fig. 8.10). In this case, a large, mobile, prolapsing, uncalcified mass is found, giving a systolic vibration. Diagnosis of such echocardiographic findings should be based on clinical picture and bacteriological blood tests.

The most reliable method for detecting vegetation is transesophageal echocardiography (Fig.16.16). Its sensitivity for clinically confirmed bacterial endocarditis exceeds 90%. We recommend carrying out transesophageal echocardiography in all cases when vegetation is not detected by transthoracic examination, but there are suspicions that the patient has bacterial endocarditis.

From the Bible book of sex author Paul Joanides

From the book Veterinarian's Handbook. Delivery Guide emergency care animals author Alexander Talko

Any heart defect is associated with a valve abnormality. Aortic valve defects are especially dangerous, since the aorta is the largest and most important artery in the body. And when the work of the apparatus supplying oxygen to all parts of the body and the brain is disrupted, a person is practically inoperative.

The aortic valve is sometimes formed in utero already with defects. And sometimes heart defects are acquired with age. But whatever the reason for the violation of the activity of this valve, medicine has already found treatment in such cases - aortic valve replacement.

Anatomy of the left side of the heart. Aortic valve functions

The four-chambered structure of the heart must work in complete harmony in order to fulfill its main function - to provide the body nutrients and blood-borne air. Our main organ consists of two atria and two ventricles.

The right and left parts are separated by an interventricular septum. There are also 4 valves in the heart that regulate blood flow. They open in one direction and close tightly so that the blood moves in only one direction.

The heart muscle has three layers: the endocardium, the myocardium (thick muscle layer) and the endocardium (outer). What's going on in the heart? Depleted blood, which has given up all the oxygen, returns to the right ventricle. Arterial blood flows through the left ventricle. We will consider in detail only the left ventricle and the work of its main valve - the aortic valve.

The left ventricle is cone-shaped. It is thinner and narrower than the right one. The ventricle is connected to the left atrium through the atrioventricular opening. Mitral leaflets are attached directly to the edges of the opening. The mitral valve is bicuspid.

The aortic valve (valve aortae) consists of 3 cusps. Three dampers are named: right, left and back crescent (valvulae semilunares dextra, sinistra, posterior). The valves are formed by a well-developed endocardial duplication.

The atrial muscles from the ventricular muscles are isolated by a plate of the right and left fibrous rings. The left annulus fibrosus (anulus fibrosus sinister) surrounds the atrioventricular opening, but not completely. Anteriorly, the ring is attached to the aortic root.

How does the left side of the heart work? Blood flows in, the mitral valve closes, and there is a shock - contraction. The contraction of the heart walls pushes blood through the aortic valve into the widest artery, the aorta.

With each contraction of the ventricle, the valves are pressed against the walls of the vessel, giving a free flow of oxygenated blood. When the left ventricle relaxes for a fraction of a second to fill the cavity with blood again, the aortic valve of the heart closes. This is one heart cycle.

Congenital and acquired aortic valve defects

If there are problems with the aortic valve during the intrauterine development of the baby, it is difficult to notice. Usually, the defect is noticed after birth, since the child's blood bypasses the valve, immediately into the aorta through the patent ductus arteriosus. It is possible to notice deviations in the development of the heart only thanks to echocardiography, and only from 6 months.

The most common valve anomaly is the development of 2 leaflets instead of 3. This heart defect is called bicuspid aortic valve. The child does not face an anomaly. But 2 sashes wear out faster. And by adulthood, supportive therapy or surgery is sometimes needed. Less commonly, a defect such as a one-leaf valve occurs. Then the valve wears out even faster.

Another anomaly is congenital stenosis of the aortic valve. The semilunar valves either grow together, or the valve fibrous ring itself, to which they are attached, is excessively narrow. Then the pressure between the aorta and the ventricle is different. Over time, the stenosis increases. And interruptions in the work of the heart prevent the child from fully developing, it is difficult for him to exercise sports even in the school gym. Severe disruption of blood flow through the aorta at some point can lead to sudden death of the child.

Acquired defects are a consequence of smoking, excessive eating, sedentary and stressful lifestyle. Since everything in the body is connected, then after 45-50 years all minor ailments usually develop into diseases. The aortic valve of the heart gradually wears out with old age, as it works constantly. The exploitation of your body's resources, lack of sleep wear out these important parts of the heart faster.

Aortic stenosis

What is stenosis in medicine? Stenosis means a narrowing of the vessel lumen. Aortic stenosis is a narrowing of the valve that separates the left ventricle of the heart from the aorta. Distinguish between minor, moderate and severe. This defect can affect the mitral and aortic valves.

With a slight valve defect, a person does not feel any pain or other signaling symptoms, because the increased work of the left ventricle will be able to compensate for the poor functioning of the valve for some time. Then, when the compensatory capabilities of the left ventricle are gradually exhausted, weakness and poor health begins.

The aorta is the main blood line. If the valve is malfunctioning, all vital organs will suffer from a lack of blood supply.

The causes of stenosis of the heart valves are:

Congenital valve defect: fibrous film, bicuspid valve, narrow ring.
A scar formed by the connective tissue just below the valve.
Infective endocarditis. Bacteria trapped in heart tissue alter the tissue. Due to the bacterial colony, connective tissue grows on tissues and valves.
Deforming osteitis.
Autoimmune problems: rheumatoid arthritis, lupus erythematosus. Due to these diseases, connective tissue grows in the place where the valve is attached. Growths are formed on which more calcium is deposited. Calcification occurs, which we will remember later.
Atherosclerosis.

Unfortunately, in most cases, aortic stenosis is fatal if valve replacement is not done on time.

Stages and symptoms of stenosis

Doctors distinguish 4 stages of stenosis. At the first one, there is practically no pain or ailments. A set of symptoms corresponds to each stage. And the more serious the stage of stenosis development, the faster the operation is needed.

The first stage is called the compensation stage. The heart is still coping with the load. The deviation is recognized as insignificant when the valve clearance is 1.2 cm 2 or more. And the pressure is 10-35 mm. rt. Art. Symptoms at this stage of the disease are not manifested.
Subcompensation. The first symptoms appear immediately after exercise (shortness of breath, weakness, palpitations).
Decompensation. It is characterized by the fact that symptoms appear not only after exercise, but also in a calm state.
The last stage is called terminal. This stage is when strong changes have already occurred in the anatomical structure of the heart.

Symptoms for severe stenosis are:

pulmonary edema;
dyspnea;
sometimes attacks of suffocation, especially at night;
pleurisy;
heart cough;
pain in the chest area.

On examination, the cardiologist detects usually moist wheezing in the lungs while listening. The pulse is weak. Noises are heard in the heart, there is a vibration created by the turbulence of blood flows.

Stenosis becomes critical when the lumen is only 0.7 cm 2. The pressure is more than 80 mm. rt. Art. At this time, the risk of death is high. And even an operation to eliminate the defect is unlikely to change the situation. Therefore, it is better to consult a doctor during the subcompensatory period.

Calcification development

This defect develops as a result of a degenerative process in the tissue of the aortic valve. Calcification can lead to severe heart failure, stroke, and general atherosclerosis. Gradually, the leaflets of the aortic valve become covered with calcareous growth. And the valve is calcified. That is, the flaps of the valve stop closing completely, but they also open weakly. When a bicuspid aortic valve forms at birth, calcification quickly renders it inoperative.

And also calcification develops as a result of disruption of the endocrine system. Calcium salts, when they do not dissolve in the blood, accumulate on the walls of blood vessels and on the valves of the heart. Or a kidney problem. Polycystic kidney disease or nephritis of the kidneys also lead to calcification.

The main symptoms will be:

aortic insufficiency;
enlargement of the left ventricle (hypertrophy);
interruptions in the work of the heart.

A person must monitor his health. Pain in the chest area and the increasingly frequent recurrent attacks of angina pectoris should be a signal to undergo a cardiac examination. Without surgery for calcification, in most cases, a person dies within 5-6 years.

Aortic regurgitation

During diastole, blood from the left ventricle is forced into the aorta by pressure. This is how the systemic circulation begins. But with regurgitation, the valve "pushes" blood back into the ventricle.

Valve regurgitation, or aortic valve insufficiency, in other words, has the same stages as valve stenosis. The reasons for this condition of the valves are either aneurysm, or syphilis, or the aforementioned acute rheumatism.

The symptoms of deficiency are:

low pressure;
dizziness;
frequent fainting;
swelling of the legs;
broken heart rate.

Severe failure leads to angina and ventricular enlargement, as with stenosis. And such a patient also needs an operation to replace the valve in the near future.

Valve seal

Stenosis can form due to the fact that endogenous factors cause the appearance of various growths on the valve leaflets. The aortic valve hardens and malfunctions begin. Many untreated diseases can be the reasons leading to the hardening of the aortic valve. For instance:

Autoimmune diseases.
Infectious lesion (brucellosis, tuberculosis, sepsis).
Hypertension. Due to prolonged hypertension, the tissues become thicker and coarser. Therefore, over time, the gap narrows.
Atherosclerosis is the clogging of tissues with lipid plaques.

Tissue thickening is also a common sign of aging in the body. Compaction will inevitably result in stenosis and regurgitation.

Diagnostics

Initially, the patient must provide all the necessary information for the diagnosis to the doctor in the form of an accurate description of the ailments. Based on the patient's medical history, the cardiologist will prescribe diagnostic procedures to provide additional medical information.

Necessarily appointed:

X-ray. The shadow of the left ventricle increases. This can be seen in the arc of the heart contour. Signs of pulmonary hypertension are also visible.
ECG. The examination reveals an enlarged ventricle and arrhythmia.
Echocardiography. On it, the doctor notices whether or not there is a seal on the valve flaps and a thickening of the walls of the ventricle.
Probing cavities. The cardiologist must know the exact meaning: how much the pressure in the aortic cavity differs from the pressure on the other side of the valve.
Phonocardiography. Noises are recorded during the work of the heart (systolic and diastolic murmurs).
Ventriculography. It is prescribed to detect insufficiency of the mitral valves.

With stenosis, the electrocardiogram shows disturbances in the rhythm and conduction of biocurrents. Signs of darkening can be clearly seen on the radiograph. This indicates congestion in the lungs. It is clearly visible how dilated the aorta and the left ventricle are. And coronary angiography shows that the amount of blood ejected from the aorta is less. This is also an indirect sign of stenosis. But angiography is done only for people over 35 years old.

The cardiologist also pays attention to symptoms that are visible without instruments. Pallor of the skin, Musset's symptom, Mueller's symptom - such signs indicate that the patient most likely has aortic valve insufficiency. Moreover, the bicuspid aortic valve is more susceptible to failure. The doctor must take into account the congenital features.

What other signs can suggest a diagnosis to a cardiologist? If, while measuring the pressure, the doctor notices that the upper is much higher than the norm, and the lower (diastolic) is too low, this is a reason to send the patient for an echocardiography and an X-ray. Excessive noises during diastole heard through a stethoscope also do not bode well for any good news. This is also a sign of failure.

Treatment with drugs

For the treatment of insufficiency at the initial stage, drugs of the following classes can be prescribed:

peripheral vasodilators, which include nitroglycerin and its analogs;
diuretics are prescribed only for certain indications;
calcium channel blockers such as Diltiazem.

If the pressure is very low, nitroglycerin preparations are combined with "Dopamine". But beta-hadron blockers are contraindicated in case of aortic valve insufficiency.

Aortic valve replacement

Aortic valve replacement operations are now being performed quite successfully. And with minimal risk.

During the operation, the heart is connected to a heart-lung machine. The patient is also given full anesthesia. How can a surgeon perform this minimally invasive operation? There are 2 ways:

The catheter is inserted directly into the femoral vein and up to the aorta against the bloodstream. The valve is secured and the tube is removed.
A new valve is inserted through an incision in the chest on the left. An artificial valve is inserted and it snaps into place, passing through the apical part of the heart, and is easily excreted from the body.

The minimally invasive operation is suitable for those patients who have concomitant diseases and cannot open the chest. And after such an operation, a person immediately feels relief, since the defects have been eliminated. And if there are no complaints about the state of health, it can be discharged in a day.

It should be noted that artificial valves require constant administration of anticoagulants. Mechanical can cause blood clotting. Therefore, after the operation, "Warfarin" is prescribed immediately. But there are also biological valves that are more suitable for humans. If a valve is installed from the porcine pericardium, then the drug is prescribed only for several weeks after the operation, and then canceled, since the tissue takes root well.

Aortic balloon valvuloplasty

Sometimes aortic balloon valvuloplasty is prescribed. This is a painless, state-of-the-art operation. The doctor controls all the actions that take place through special X-ray equipment. A catheter with a balloon is passed to the aortic orifice, then the balloon is inserted into the valve site and expanded. This eliminates the problem of valve stenosis.

Who is the operation indicated for? First of all, such an operation is performed on children with a congenital defect, when a unicuspid or bicuspid aortic valve is formed instead of a tricuspid one. It is indicated for pregnant women and people before another heart valve transplant.

After this operation, the recovery period is only 2 days to 2 weeks. Moreover, it is transferred very easily and is suitable for people with poor health, and even children.

Definition: aortic valve insufficiency (aortic insufficiency) is a heart defect in which the semilunar cusps of the aortic valve do not completely close the aortic opening during left ventricular diastole. The result is a reverse flow of blood from the aorta to the left ventricle (aortic regurgitation).

Etiology of aortic insufficiency: - against the background of a number of diseases, anatomical changes of the aortic valve occur, leading to its insufficiency. Against the background of rheumatic endocarditis, wrinkling and shortening of the semilunar valves occurs as a result of the inflammatory-sclerotic process. With infectious (septic) endocarditis (ulcerative endocarditis), partial decay occurs with the formation of defects, followed by scarring and shortening of the valve leaflets. In syphilis, atherosclerosis of some systemic connective diseases (rheumatoid arthritis, ankylosing spondylitis), the main role in the formation of aortic insufficiency is played mainly by the defeat of the aorta itself. As a result of the expansion of the aorta and its valve ring, the semilunar cusps are pulled back with their incomplete closure. It is extremely rare that aortic insufficiency occurs in the background closed injury chest with rupture or tearing of the valve leaflets.

Due to the fact that the valve flaps do not completely close the lumen of the aortic opening, during diastole, blood enters the left ventricle not only from the left atrium, but also from the aorta due to reverse blood flow (aortic regurgitation) during diastolic relaxation of the left ventricle, the pressure in it is lower than in the aorta. This leads to overflow and more stretching of the left ventricle during diastole. During systole, the left ventricle, contracting with greater force, ejects an increased volume of blood into the aorta. The volume load causes an increase in the work of the left ventricle, which leads to its hypertrophy. Thus, there is hypertrophy, and then dilatation of the left ventricle. Increased cardiac output in systole and aortic regurgitation in diastole, leading to a sharper than normal drop in pressure in the aorta and arterial system in the diastolic period. An increased systolic blood volume in comparison with the norm causes an increase in systolic blood pressure, the return of some of the blood to the ventricle leads to a more rapid drop in diastolic pressure, the values \u200b\u200bof which become lower than normal. A sharp fluctuation in pressure in the arterial system causes an increased pulsation of the aorta and arterial vessels.

The defect is compensated by the enhanced work of the powerful left ventricle, so the patient's well-being can remain satisfactory for a long time. However, over time, complaints appear.

The main complaints may be: - pain in the region of the heart, similar to angina pectoris. They are caused by coronary insufficiency due to an increase in oxygen demand against the background of myocardial hypertrophy and increased work of the left ventricle, as well as a decrease in the blood filling of the coronary arteries with low diastolic pressure in the aorta.

Dizziness: sensations of "noise" and "pulsation" in the head occur due to malnutrition of the brain against the background of sharp fluctuations in blood pressure and low diastolic pressure. With the decompensation of the defect, symptoms of heart failure appear: decreased exercise tolerance, inspiratory dyspnea, palpitations. With the progression of heart failure, there may be: - cardiac asthma, pulmonary edema.

Inspection (a number of symptoms are revealed):

1. Pallor of the skin (low blood circulation in the arterial system during diastole due to low diastolic blood pressure).

2. Pulsation of peripheral arteries (an increase in systolic blood pressure against a background of a larger than normal stroke volume of the left ventricle; and a rapid decrease in diastolic blood pressure against a background of aortic regurgitation).

Pulsation: carotid arteries ("dance of carotids"); subclavian, shoulder, temporal, etc.

Rhythmic head shaking, synchronous with the arterial pulse (Musse symptom) - occurs in severe aortic insufficiency due to pronounced vascular pulsation due to mechanical transmission of vibrations.

Rhythmic change in the color of the nail bed when pressing on the end of the nail (Quincke's capillary pulse). A more accurate name is Quincke's pseudocapillary pulse, because it is not the capillaries that pulsate, but the smallest arteries and arterioles. It is noted with severe aortic insufficiency.

A similar origin are: - pulsatory hyperemia of the soft palate, pulsation of the iris, rhythmic increase and decrease in the area of \u200b\u200bredness of the skin after friction.

When examining the region of the heart, an apical impulse that is enlarged in area and displaced down and to the left is often noticeable (the result of intensive work against the background of a load of the volume of the hypertrophied left ventricle).

Palpation

On palpation, the displacement of the apical impulse is determined in the sixth, sometimes in the seventh intercostal space, outward from the midclavicular line. The apical impulse is enhanced, diffuse, elevating, domed, which indicates a large increase in the left ventricle and its hypertrophy.

Percussion

Percussion noted displacement of the borders of cardiac dullness to the left. In this case, the configuration of cardiac dullness, which has a pronounced cardiac waist (aortic configuration), is determined percussion.

Auscultation

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Ultrasound of the heart: the purpose of the study

Preparation for the procedure and ultrasound

Decoding: normal indicators

Possible heart disease on ultrasound

Ultrasound of the heart during pregnancy

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Normal indicators of echocardiography, Doppler

Ultrasound for everyone!

Mitral valve prolapse on ultrasound of the heart

Mitral and aortic heart valves - norms for ultrasound

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Encyclopedia of Ultrasound and MRI

Ultrasound diagnostics of the heart: norms and ultrasound pathologies

Indications and contraindications

Training

How is the diagnosis carried out?

Research results: deviations and norms

Normal results

Ultrasound signs of pathologies

Mitral valve stenosis

Lack of mitral valve

Tricuspid valve pathology

Conclusion

Cardiology ultrasound of the heart

Deciphering the normal indicators of ultrasound of the heart

What allows you to examine (EchoCG)

When to do (Echo KG)

What diseases is diagnosed by ultrasound of the heart

Echocardiography interpretation

Heart ultrasound

What is heart ultrasound

What diseases can be detected

Heart ultrasound rates

Ultrasound examination of the heart

Research methods

What preparation includes before the study

Echocardiography

Indicators and their parameters

Ultrasound anatomy of the heart in various echolocation modes

Aortic stenosis

Hypertrophic cardiomyopathy

Dilaticiotshm cardiomyopia

List of references

PHONOCARDIOGRAPHY

Anatomy of the left side of the heart. Aortic valve functions

Congenital and acquired aortic valve defects

Aortic stenosis

Stages and symptoms of stenosis

Calcification development

Aortic regurgitation

Valve seal

Diagnostics

Treatment with drugs

Aortic valve replacement

Aortic balloon valvuloplasty

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