Aortic insufficiency. Characteristics of valve movement according to echocardiography

Front flap mitral valve without signs of pathology is recorded in the second standard position of the sensor in the form of the letter M.
For a more complete understanding and subsequent interpretation of parameters, reflecting the mechanism of the mitral valve, we consider it appropriate to provide a descriptive description of the movement according to the diagram.

General excursion of the mitral valve is determined in systole by the vertical displacement of the valves in the SD interval, diastolic discrepancy is determined horizontally in the interval of the SD segment. The speed of early diastolic opening and closing is calculated graphically using the method described above by constructing tangents to the corresponding sections of the mitral valve movement curve.

Semilunar valves. The aortic valves and the aorta itself are located in the IV standard position of the sensor. In diastole, the valves are recorded on the echocardiogram in the form of a “snake” in the center of the aortic lumen. The divergence of the aortic valves in systole resembles a “diamond-shaped figure.”

Systolic aortic valve divergence equal to the distance between their terminal sections facing the lumen of the aorta. The lumen of the aorta in systole and diastole is determined by the outlines of its inner surface in the corresponding phases of the cardiac cycle relative to the ECG.

Left atrium, like the aorta, is recorded in the IV standard position of the sensor. The echocardiogram shows almost only the posterior wall of the left atrium. Its anterior wall in echocardiography is considered to coincide with the posterior surface of the aorta. According to these signs, the size of the cavity of the left atrium is determined.

Normal EchoCG (echocardioscopy)

Average echocardiographic parameters are normal(according to literature):
Left ventricle.
The thickness of the posterior wall of the left ventricle is 1 cm in diastole and 1.3 cm in systole.
The end-diastolic size of the left ventricular cavity is 5 cm.
The final systolic size of the left ventricular cavity is 3.71 cm.
The rate of contraction of the posterior wall of the left ventricle is 4.7 cm/s.
The relaxation rate of the posterior wall of the left ventricle is 10 cm/s.

Mitral valve.
The total excursion of the mitral valve is 25 mm.
Diastolic divergence of the mitral leaflets (at the level of point E) is 26.9 mm.
The opening speed of the transition flap (EG) is 276.19 mm/s.
The speed of early diastolic closure of the anterior wall is 141.52 mm/s.

The valve opening duration is 0.47±0.01 s.
The opening amplitude of the front leaf is 18.42±0.3& mm.
The lumen of the base of the aorta is 2.52±0.05 cm.
The size of the cavity of the left atrium is 2.7 cm.
End diastolic volume - 108 cm3.

The final systolic volume is 58 cm3.
Stroke volume - 60 cm3.
Exile faction - 61%.
The speed of circular contraction is 1.1 s.
The mass of the left ventricular myocardium is 100-130 g.

Aortic insufficiency is a pathological change in the functioning of the heart, characterized by non-closure of the valve leaflets. This leads to reverse blood flow from the aorta to the left ventricle. Pathology has serious consequences.

If you do not get treatment on time, then everything becomes complicated. Organs do not receive the required amount of oxygen. This causes the heart to beat faster to make up for the shortfall. If you do not intervene, the patient is doomed. After a certain time, the heart enlarges, then swelling appears, and due to pressure surges inside the organ, the left atrium valve may fail. It is important to consult a therapist, cardiologist or rheumatologist in time.

Aortic insufficiency is divided into 3 degrees. They differ in the divergence of the valve flaps. At first glance, it looks simple. This:

• Sinuses of Valsalva - they are located behind the aortic sinuses, just behind the valves, which are often called semilunar sinuses. The coronary arteries begin from this place.
• The fibrous ring is highly durable and clearly separates the beginning of the aorta and the left atrium.
• There are three semilunar valves; they continue the endocardial layer of the heart.

The doors are arranged in a circular line. When the valve closes in a healthy person, there is completely no gap between the valves. The degree and severity of aortic valve insufficiency depends on the size of the convergence gap.

First degree

The first degree is characterized by mild symptoms. The discrepancy between the valves is no more than 5 mm. It feels no different from the normal state.

Failure aortic valve Grade 1 manifests itself with mild symptoms. With regurgitation, the blood volume is no more than 15%. Compensation occurs due to increased impulses of the left ventricle.

Patients may not even notice pathological manifestations. When the disease is in the compensation stage, therapy may not be carried out; preventive actions are limited. Patients are prescribed observation by a cardiologist, as well as regular ultrasound checks.

Second degree

Aortic valve insufficiency, which belongs to the 2nd degree, has symptoms with a more pronounced manifestation, while the divergence of the valves is 5-10 mm. If this process occurs in a child, then the signs are subtle.

If, when aortic insufficiency occurs, the volume of blood returning is 15-30%, then the pathology is classified as a second-degree disease. Symptoms are not severe, but shortness of breath and rapid heartbeat may occur.

To compensate for the defect, the muscles and valve of the left atrium are used. In most cases, patients complain of shortness of breath with light exertion, increased fatigue, strong heartbeat and pain.

During examinations using modern equipment, increased heartbeat is detected, the apical impulse moves slightly downward, and the boundaries of cardiac dullness expand (to the left by 10-20 mm). When using X-ray examination, downward enlargement of the left atrium is visible.

Using auscultation, you can clearly hear murmurs along the sternum on the left side - these are signs of an aortic diastolic murmur. Also, with the second degree of insufficiency, systolic murmur appears. As for the pulse, it is increased and pronounced.

Third degree

The third degree of insufficiency, also called severe, has a discrepancy of more than 10 mm. Patients require serious treatment. More often, surgery is prescribed followed by drug therapy.

When the pathology is at stage 3, the aorta loses more than 50% of the blood. To compensate for the loss, the heart organ increases its rhythm.

Basically, patients often complain of:

• shortness of breath at rest or with minimal exertion;
• pain in the cardiac region;
• increased fatigue;
• constant weakness;
• tachycardia.

Research reveals a strong increase in the size of the borders of cardiac dullness down and to the left. Displacement also occurs in the right direction. As for the apical impulse, it is intensified (spread out).

In patients with the third degree of insufficiency, the epigastric region pulsates. This indicates that the pathology involved the right chambers of the heart.

During the examination, a pronounced systolic, diastolic and Flint murmur appears. They can be heard in the area of ​​the second intercostal space on the right side. They have a distinct character.

It is important to seek help at the first, even minor, symptoms. medical care to therapists and cardiologists.

Symptoms, signs and causes

When aortic valve insufficiency begins to develop, symptoms do not appear immediately. This period is characterized by the absence of serious complaints. The load is compensated by the left ventricular valve - it is able to resist reverse flow for a long time, but then it stretches and becomes slightly deformed. Already at this time, pain, dizziness and rapid heartbeat occur.

The first symptoms of deficiency:

• there is a certain sensation of pulsation of the neck veins;
• strong tremors in the heart area;
• increased frequency of contraction of the heart muscle (minimization of reverse blood flow);
• pressing and squeezing pain in the area chest(with strong reverse blood flow);
• the occurrence of dizziness, frequent loss of consciousness (occurs when there is poor oxygen supply to the brain);
• the appearance of general weakness and decreased physical activity.

During chronic disease the following symptoms appear:

• pain in the cardiac region even in a calm state, without stress;
• during exercise, fatigue appears quite quickly;
• constant ringing in the ears and a feeling of strong pulsation in the veins;
• the occurrence of fainting during a sudden change in body position;
• severe headache in the front area;
• pulsation of arteries visible to the naked eye.

When the pathology is in a decompensatory degree, metabolism in the lungs is disrupted (often observed by the appearance of asthma).

Aortic insufficiency is accompanied severe dizziness, fainting, as well as pain in the chest cavity or its upper parts, frequent shortness of breath and irregular heartbeat.

Causes of the disease:

• congenital aortic valve defect.
• complications after rheumatic fever.
• endocarditis (the presence of bacterial infection of the inside of the heart).
• changes with age - this is explained by wear and tear of the aortic valve.
• an increase in the size of the aorta - a pathological process occurs with hypertension in the aorta.
• hardening of the arteries (as a complication of atherosclerosis).
• aortic dissection, when the inner layers of the main artery separate from the middle layers.
• impaired functionality of the aortic valve after its replacement (prosthetics).

Less common reasons include:

• aortic valve injuries;
• autoimmune diseases;
• consequences of syphilis;
• ankylosing spondylitis;
• manifestations of diffuse type diseases associated with connective tissues;
• complications after the use of radiation therapy.

It is important to consult a doctor at the first manifestations.

Features of the disease in children

Many children do not notice problems for a long time and do not complain about illness. Most of the time they do well, but it doesn't last long. Many are still able to engage in sports training. But the first thing that torments them is shortness of breath and increased heart rate. If these symptoms occur, it is important to immediately contact a specialist.

At first, unpleasant sensations are noticed with moderate loads. In the future, aortic valve insufficiency occurs even in a calm state. Worried about shortness of breath, strong pulsation of the arteries located in the neck. Treatment must be of high quality and timely.

Symptoms of the disease may appear as murmurs in the area of ​​the largest artery. As for physical development, in children it does not change with insufficiency, but there is a noticeable pallor of the facial skin.

When examining the echocardiogram, aortic valve insufficiency is expressed as a moderate increase in the lumen at the mouth of the artery. There are also noises in the area of ​​the left side of the chest, which indicates the progress of the discrepancy between the lobes of the semilunar valves (more than 10 mm). Strong shocks are explained by the increased work of the left ventricle and atrium in compensation mode.

Diagnostic methods

To correctly assess changes in the functionality of the heart and its systems, you need to undergo high-quality diagnostics:

1. Dopplerography;
2. X-ray (effectively detects pathological changes in valves and heart tissue);
3. echocardiography;
4. phonocardiography (determines murmurs in the heart and aorta);

During the inspection, specialists pay attention to:

• complexion (if it is pale, this means insufficient blood supply to small peripheral vessels);
• rhythmic dilation of the pupils or their constriction;
• state of the tongue. Pulsations change its shape (noticeable upon examination);
• shaking of the head (involuntary), which occurs in rhythm with the heart (this is caused by strong shocks in the carotid arteries);
• visible pulsation of the cervical vessels;
• heart beats and their strength upon palpation.

The pulse is unstable, there are decreases and increases. By using auscultation of the heart organ and its vessels, murmurs and other signs can be identified more quickly and accurately.

Treatment

At the very beginning, aortic insufficiency may not require special treatment (first degree); only prevention methods are applicable. Later, therapeutic or cardiac treatment is prescribed. Patients must follow the recommendations of specialists regarding the way they organize their life activities.

It is important to limit physical activity, stop smoking or drinking alcohol, and be systematically examined with an ultrasound or ECG.

At drug treatment Doctors prescribe diseases:

If the disease is in the last stage, then only surgical intervention will help.

Cases when a patient needs urgent consultation with a surgeon:

• when the state of health has sharply deteriorated, and the reverse ejection towards the left ventricle is 25%;
• in case of disturbances in the functioning of the left ventricle;
• when 50% of blood volume is returned;
• a sharp increase in the size of the ventricle (more than 5-6 cm).

Today there are two types of operations:

1. Surgical intervention associated with implantation. It is performed when the backflow of the aortic valve is more than 60% (it is worth noting that today biological prostheses are almost never used).
2. Operation in the form of intra-aortic balloon counterpulsation. It is done when there is slight deformation of the valve leaflets (at 30% blood ejection).

Aortic insufficiency may not occur if preventive actions aimed against rheumatic, syphilis and atherosclerotic pathologies are taken in a timely manner.

It is surgical help that helps get rid of the problems in question. The timeliness and quality of taking measures can greatly increase the chance of a person returning to normal life.

You may also be interested in:

Signs coronary disease hearts in men: diagnostic methods
Shortness of breath in heart failure and its treatment with folk remedies

This is a safe procedure that can be performed on both children and adults.

Ultrasound of the heart: purpose of the study

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

An ultrasound examination is prescribed in the following cases:

Indications for ultrasound also include the rehabilitation period after heart surgery or a heart attack. If there are jumps blood pressure, dizziness, swelling, weakness, then an ultrasound examination 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, bluish skin, heart murmurs, etc.

Ultrasound of the heart helps determine the norm and abnormalities in the functioning of this organ, assess the size, beat frequency, 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 performed along with Doppler ultrasound to assess blood flow.

This study is absolutely safe and can be performed at any age. There are no contraindications to ultrasound, but it makes it difficult to perform the study big size breasts in women, chest deformation, attacks of bronchial asthma.

Preparation for the procedure and ultrasound examination

Ultrasound examination of the heart

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

The day before the test, you should stop drinking alcohol and energy drinks, as heart rate distortion may occur. You should not smoke before the test. Nicotine slows your heart rate, which can cause misleading results.

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

Please be aware that results may not be accurate. This 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 runs the sensor across the chest, examining any part of the heart muscle.

If necessary, 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 fat, 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 presumed diagnosis.

Explanation: normal indicators

Depending on the patient's age normal indicators will be different. This is also affected by existing chronic diseases.

Normal ultrasound findings:

• 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 orifice is in the range of 1.7-2.4 cm.
• The size of the aortic valve (AV) is 1.5-2.6 cm, the left atrium (LA) is 1.9-4.0 cm, the right atrium (RA) is 2.7-4.5 cm.
• When the heart muscle relaxes, the volumes of the ventricles change. For the right, the normal value 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 valves, the blood flow velocity should normally be 0.6-1.3 m/sec. The speed of transcuspid blood flow is in the range of 0.3-0.7 m/sec, transpulmonary – 0.6-0.9 m/sec, and in the terminal section of the left ventricle – 0.7-1.1 m/sec.
• In women and men, myocardial mass is significantly different and amounts to 95 g and 135 g, respectively.
• During one contraction, the amount of blood ejected by the left ventricle is ml.
• The mitral valve leaflets must have a smooth surface; when the heart muscle contracts during systole, their deflection into the left atrium is normally no more than 2 mm.
• The aortic valve leaflets should be identical, fully opening in systole and closing in diastole.

Interpretation of results should only be carried out by a qualified physician.

Possible heart disease on ultrasound

Changes in heart parameters are a sign of organ pathology

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

• When the thickness of the vessel walls increases, 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 blood vessels, then this is one of the signs of cardiac pathology.
• If the blood flow rate is reduced, this indicates a valve defect.
• A low volume of blood ejected by the heart with each contraction indicates heart failure or blood congestion.

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

• Congenital and acquired defects (ventricular and atrial septal defects, patent ductus arteriosus, stenosis of the mitral and aortic valves)
• Ischemic disease
• Heart rhythm disturbances
• Heart failure
• Pericarditis
• Endocarditis
• Pulmonary hypertension

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

Ultrasound of the heart during pregnancy

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

The study is prescribed for pregnant women, since it is during this period that the load on all the woman’s organs is significantly increased. It is important to monitor the condition of the woman and the fetus. This is an optional test and is carried out only as directed by a doctor.

Purpose of ultrasound examination during pregnancy:

• liver enlargement
• fatigue, shortness of breath
• chronic vascular diseases
• slowing and increased heart rate
• pain in the heart area
• previous heart surgery
• blood clots in blood vessels

If a pregnant woman periodically loses consciousness, her skin turns blue and her hands get cold, then this is a reason to see a doctor for an examination. It is also important to check your heart function if a 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 an electrocardiogram there are abnormalities in the functioning of the heart, then ultrasound diagnostics is also indicated.

Before a caesarean section is performed under general anesthesia, a cardiac examination is also prescribed.

If you have existing cardiovascular diseases or some of the above symptoms, an ultrasound diagnosis is required. If there is a cardiac pathology, the doctor should prescribe the necessary medicines to maintain the activity of the heart muscle, which will allow you to bear and give birth to a healthy baby.

More information about cardiac ultrasound can be found in the video:

To determine the normal development of the fetus and the structure of all organs, an intrauterine ultrasound is performed. The study is performed in the first trimester of pregnancy from 18 to 20 weeks. If congenital pathologies of the fetal heart are detected, the doctor will determine the type of delivery. There are situations when, after giving birth, the baby requires urgent surgery and emergency medical care.

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Comments

An ultrasound of the heart was done to me only once, and if previously it was diagnosed as a mitral valve defect, then the ultrasound showed that the valve was normal, but a little soft, due to this it bends and there is a slight noise.

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The content of this page is for educational and informational purposes only and cannot and does not constitute a public offer, which is defined 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 specialist

Normal indicators of echocardiography, Dopplerography

Aortic valve: systolic divergence of the leaflets

Blood flow speed - up to 1.7 m/sec

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 - 7-11mm, excursion - 6-8 mm

Diastolic divergence of mitral valve leaflets - mm

The speed of early diastolic closing of the anterior leaflet is 9-15 m/sec.

Hole area - 4-6 sq.cm

Blood flow speed is 0.6-1.3 m/sec.

Pressure gradient - 1.6-6.8 mm Hg. Art.

Tricuspid valve: blood flow speed - 0.3-0.4 m/sec

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 normal area of ​​the mitral orifice is about 4 cm2. With mitral stenosis, clinical symptoms appear at S = 2.5 cm 2.

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

S > 2 cm 2 - mild stenosis;

S = 1-2 cm 2 - moderate stenosis (moderate);

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

The severity of aortic stenosis, taking into account the S of the aortic opening.

S = 1.5 cm 2 - initial aortic stenosis;

S = 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

Assessing the severity of mitral regurgitation (MR)

Ultrasound for everyone!

Mitral valve prolapse on cardiac ultrasound

Mitral valve prolapse is the abnormal prolapse (bending) of one or both mitral valve leaflets into the cavity of the left atrium during systole (contraction) of the left ventricle.

This condition may be due to a number of reasons: structural changes in the leaflets, annulus fibrosus, chordae, papillary muscles, or impaired contractility of the left ventricular myocardium. Slight sagging of the mitral valve leaflet or leaflets may occur in people asthenic build, 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 approaches and modes of echocardiography. With the help of ultrasound of the heart, it is possible to detect not only prolapse of the valves, but also to evaluate their structure and functional characteristics of the heart.

Ultrasound of the heart in one-dimensional mode can reveal the following signs characteristic of mitral stenosis:

Thickening of the anterior, posterior or both leaflets of the mitral valve by more than 5 mm, their hypoechogenicity.

Let me explain right away what a one-dimensional mode in ultrasound is. It is also called M-mode. This is a research mode in which we get an image of a cross-section of an organ. B – mode is a two-dimensional ultrasound mode. Just the 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 an ultrasound in duplex mode we see this blood flow. Hemodynamically significant regurgitation means that this process causes changes in the parts of the heart - expansion of the cavities.

B-mode ultrasound reveals the following signs of mitral valve prolapse:

Sagging of one of the leaflets or both leaflets into the cavity of the left atrium during left ventricular systole by more than 2 mm.

Sealing of the mitral valve leaflets.

Enlargement of the mitral annulus.

Tricuspid valve prolapse is also often detected.

With hemodynamically significant mitral regurgitation, there is an enlargement of the left chambers of the heart.

Echocardiography determines the degree of mitral valve prolapse.

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

III degree (moderate) 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 reveal mitral valve regurgitation. Its severity also determines the degree of mitral valve prolapse.

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

Mitral and aortic valves of the heart - normal on 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 heart area or have cardiac diseases, then do not put off visiting a doctor!

Be sure to identify the anterior and posterior leaflets, two commissures, chords and papillary muscles, and the mitral annulus.

The thickness of the mitral valves is up to 2 mm;

The diameter of the fibrous ring is 2.0-2.6 cm;

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

Mitral orifice area cm 2.

The circumference of the left atrioventricular orifice is 6–9 cm;

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

Active but smooth movement of the valves;

Smooth surface of the doors;

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

The chordae are visible as thin, linear structures;

Some normal indicators:

Systolic opening of the leaflets is greater than;

Aortic opening area cm 2.

The doors are proportionally identical;

Full opening in systole, close well in diastole;

The aortic ring is 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 organ has a rather complex both structural and functional organization. To diagnose cardiac 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 a clinical examination.

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

There are currently no contraindications to performing ultrasound of the heart, as well as contraindications to performing ultrasound examination.

There are some restrictions, for example, when performing a transthoracic ultrasound of the heart on people with significant subcutaneous fat or injuries in the area of ​​the procedure, or with a pacemaker installed.

There is difficulty in performing an ultrasound in the presence of increased airiness of the lungs, which, expanding, cover the heart, and the change in phases of the medium reflects the ultrasound.

Preparation

Before performing a cardiac ultrasound, no special preparation is required, there is no need for diet or changes 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 an ultrasound, it is not recommended to use substances that can affect the rhythm and conductivity of the heart (do not smoke 2 hours before). 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 insertion of the sensor.

How is diagnostics carried out?

Ultrasound examination of the heart can be performed in different ways. The most common uses are transthoracic and transesophageal methods.

With the transthoracic ultrasound method, the sensor is installed on the sternum in its middle and lower thirds and on the left region of the chest. The subject lies on his left side. A special acoustic gel is applied to the projection area of ​​the organ being examined to facilitate ultrasound. The procedure usually lasts no more than half an hour.

Transesophageal ultrasound is performed after installing an ultrasound probe into the lumen of the esophagus. In the latter case, there are no obstacles to 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 directly adjacent to it, without the pericardium. However, installing a sensor in the esophagus can cause significant inconvenience for the subject; in such cases, specific preparation is required - general anesthesia.

Another way to carry out ultrasound diagnostics diseases of cardio-vascular system is stress echocardiography. This method involves performing an ultrasound of the heart after stimulating its work. For this purpose, special medications or physical activity can be used.

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

Doppler ultrasound is a separate option. 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 disturbances in blood flow, specifically for the heart - in its cavities. By determining the speed and direction of blood flow, it is possible to determine the condition of the valves: normal, insufficiency or stenosis.

Diagnosis of the fetal heart

To determine the condition 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

1. During cardiac ultrasound, the aorta is first examined and evaluated. In the ascending section, its diameter normally does not exceed 40 mm. The pulmonary artery is normally between 11 and 22 mm.
2. Indicators of the left atrium: its size should be from 20 to 36 mm.
3. Right ventricle: wall thickness – 2–4 mm, diameter ranges from 7 to 26 mm.
4. Left ventricle: end-diastolic diameter 37–55 mm,
5. final systolic diameter 26–37 mm,
6. diastolic volume 55–149 ml,
7. systolic volume 18–40 ml (respectively, ejection fraction 55–65%),
8. rear wall thickness 9–11 mm.
9. The thickness of the interventricular septum is 9–10 mm (decreases slightly during systole).
10. The maximum speed of blood flow through the mitral valve is 0.6 – 1.3 m/s,
11. through the tricuspid valve 0.3 – 0.7 m/s,
12. the area of ​​the left atrioventricular orifice is about 5 cm², the right one is about 6 cm²,
13. The thickness of the valves should be no more than 2 mm.
14. The valves are normally smooth, close completely during ventricular systole and prolapse by no more than 2 mm, and open without stenosis during atrial systole.
15. Aortic valve: opening area is 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 thickening of the wall of the left ventricle. There are also possible findings that may be the cause of hypertension: coarctation of the aorta (narrowing after the left subclavian artery departs from the arch - at the site of the ligamentum arteriosus) or disruption of the normal functioning of the aortic valve (stenosis), expansion of the aorta in the ascending section. In addition, atherosclerotic plaques found in the aortic ostium can cause hypertension.
• Valvular heart defects. Such disorders are characterized by stenosis of the valve openings or, conversely, valve insufficiency. The mitral valve is most often affected.

Mitral valve stenosis

With its stenosis, the most important sign will be a decrease in the area of ​​the left atrioventricular orifice, early closure of the valve leaflets (earlier than the tricuspid valve leaflets), then signs of slower opening of the valve during atrial systole may appear, thickening of the wall of the left atrium, expansion of its cavity, much later - thickening of the walls of the right ventricle and right atrium, decreased filling of the left ventricle and, accordingly, ejection into the aorta.

Mitral valve insufficiency

This pathology is characterized by the presence of reverse blood flow (regurgitation) during systole from the left ventricle back to the left atrium: in mild stage this is 30% of the ejection fraction, in moderate - up to 50%, in severe - most of the atrium volume is filled not with blood from the pulmonary veins, but from the left ventricle. Compensatory hypertrophy of the left ventricular wall and enlargement of its cavity develop later. Rheumatic diseases most often cause just such a heart defect.

Tricuspid valve pathologies

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

• Aortic defects: stenosis is characterized by a decrease in the area of ​​the 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 cavity of the left ventricle. The indicators are the same: 30% reflux - 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 severity levels 5 mm, 5 –10 mm and more than 10 mm).
• Pulmonary valve defects are similar in manifestations to aortic valve defects, but are much less common.
• Bacterial endocarditis creates a picture of aortic (usually) insufficiency due to a change in the normal configuration of the valve leaflets. In addition to the heart changes characteristic of aortic insufficiency, the ultrasound picture of the valves reveals bacterial vegetations, which are the basis for the diagnosis.
• Post-infarction state.

Myocardial infarction is usually diagnosed using faster and simpler tests (ECG), which allow an acute diagnosis to be made and emergency measures to be initiated. Therefore, ultrasound is used more to assess damage to the heart muscle. pathological process and clarification of the source of the infarction.

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

Complications of myocardial infarction detected on ultrasound can be: cardiac aneurysm (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 of the cavity of the heart sac with blood, an increase in pressure there and disruption of the heart), rupture of the papillary muscle (it holds the mitral valve leaflet, respectively, when the muscle ruptures, ultrasound shows signs of valve insufficiency) and others.

After a myocardial infarction or during its acute period, conduction or heart rhythm disturbances may appear.

• Disturbances of myocardial rhythm and conductivity.

Again, electrocardiography is of decisive importance in making a diagnosis, but ultrasound can be used to clarify the nature of the disorder: clarifying the rhythm of contraction of individual chambers, identifying changes in the structure of the myocardium (post-infarction scar), which may be the cause of various conduction disorders, extrasystoles.

Pericarditis can be dry (inflammation of the pericardial sac), effusion (fluid appears in the cavity - exudate) and constrictive (after effusion, fibrin adhesions can form between the layers of the pericardium, which limit the movements of the heart). An ultrasound can better determine the accumulation of fluid, which looks like an expansion of the hypoechoic strip around the heart. Also, the purpose of ultrasound is to control the passage of the puncture needle to aspirate this fluid.

Conclusion

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

Cardiology ultrasound of the heart

Interpretation of normal cardiac ultrasound indicators

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

Echocardiography (Echo CG) is a non-invasive diagnostic method that is highly informative, safe, and can be used for people of different ages. age category, including newborn children and pregnant women. This examination method does not require special preparation and can be carried out at any convenient time.

Unlike an X-ray examination, (Echo CG) 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 examination (EchoCG)

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

This examination also shows the condition of the myocardium, pericardium, large vessels, the mitral valve, the size and thickness of the walls of the ventricles, determines the condition of the valve structures and other parameters of the heart muscle.

After the examination (Echo CG), the doctor records the results of the examination in a special protocol, the decoding of which allows one to detect cardiac diseases, deviations from the norm, anomalies, pathologies, also make a diagnosis and prescribe appropriate treatment.

When should it be performed (Echo CG)

The earlier pathologies or diseases of the heart muscle are diagnosed, the greater the chance of a positive prognosis after treatment. An ultrasound should be performed for the following symptoms:

• periodic or frequent pain in the heart;
• rhythm disturbances: arrhythmia, tachycardia;
• dyspnea;
• increased blood pressure;
• signs of heart failure;
• previous myocardial infarction;
• if there is a history of heart disease;

You can undergo this examination not only with the direction of a cardiologist, but also with other doctors: endocrinologist, gynecologist, neurologist, pulmonologist.

What diseases can be diagnosed by cardiac ultrasound?

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

1. ischemic disease;
2. myocardial infarction or pre-infarction condition;
3. arterial hypertension and hypotension;
4. congenital and acquired heart defects;
5. heart failure;
6. rhythm disturbances;
7. rheumatism;
8. myocarditis, pericarditis, cardiomyopathy;
9. vegetative – vascular dystonia.

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

These examination results are reviewed by the attending cardiologist and, if any deviations are present, he prescribes treatment measures.

Decoding a heart ultrasound consists of multiple points and abbreviations that are difficult for a person who does not have a special medical education to understand, so we will try to briefly describe the normal indicators obtained by a person who does not have abnormalities or diseases of the cardiovascular system.

Decoding echocardiography

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

1. Left ventricular myocardial mass (LVMM):
2. Left ventricular myocardial mass index (LVMI): g/m2;
3. Left ventricular end-diastolic volume (EDV): 112±27 (65-193) ml;
4. End-diastolic size (EDD): 4.6 – 5.7 cm;
5. End systolic size (ESR): 3.1 – 4.3 cm;
6. Wall thickness in diastole: 1.1 cm
7. Long axis (LO);
8. Short axis (KO);
9. Aorta (AO): 2.1 – 4.1;
10. Aortic valve (AV): 1.5 – 2.6;
11. Left anterior (LA): 1.9 – 4.0;
12. Right atrium (RA); 2.7 – 4.5;
13. Diastological thickness of the myocardium of the interventricular septum (TMVSD): 0.4 – 0.7;
14. Thickness of the myocardium of the interventricular septum systological (TMVPS): 0.3 – 0.6;
15. Ejection fraction (EF): 55-60%;
16. Miltra valve (MK);
17. Myocardial movement (MM);
18. Pulmonary artery (PA): 0.75;
19. Stroke volume (SV) is the amount of blood volume ejected by the left ventricle in one contraction: ml.
20. Diastolic size (DS): 0.95-2.05 cm;
21. 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 expected or exact diagnosis of the patient. Depending on the purpose of the examination, the person’s health status, age and gender of the patient, the examination may show slightly different results.

A complete interpretation of echocardiography is assessed by a cardiologist. Independent study of cardiac parameters 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 interpret echocardiography and answer the patient’s questions.

Some indicators may deviate slightly from the norm or be recorded in the examination protocol under other points. 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 that should be performed once or twice a year for prevention, or after the first ailments from the cardiovascular system. The results of this examination allow a medical specialist to detect cardiac diseases, disorders and pathologies in the early stages, as well as carry out treatment, give useful recommendations and return a person to a full life.

Ultrasound of the heart

The modern world of diagnostics in cardiology offers various methods, which allow timely identification of pathologies and abnormalities. One such method is cardiac ultrasound. Such an examination has many advantages. These are high information content and accuracy, ease of implementation, a minimum of possible contraindications, and the absence of complex preparation. Ultrasound examinations can be performed not only in specialized departments and offices, but also even in the intensive care unit, in regular wards of the department, or in an ambulance during urgent hospitalization of a patient. Various portable devices, as well as the latest equipment, help with such ultrasound of the heart.

What is cardiac ultrasound

With the help of this examination, an ultrasound specialist 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 necessary for examination, so that the doctor can formulate his conclusion. Each position implies its own sensor position or access. Each position of the sensor gives the doctor the opportunity to see different structures of the heart and examine the vessels. Many patients notice that during a cardiac ultrasound, the sensor is not just placed on the chest, but also tilted or rotated, which allows you to see different planes. In addition to standard accesses, there are also additional ones. They are used only when necessary.

What diseases can be detected

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

• cardiac ischemia;
• examinations for arterial hypertension;
• aortic diseases;
• pericardial diseases;
• intracardiac formations;
• cardiomyopathy;
• myocarditis;
• endocardial damage;
• acquired valvular heart defects;
• study of mechanical valves and diagnosis of dysfunction of valve prostheses;
• diagnosis of heart failure.

For any complaints about bad feeling, if you experience pain and discomfort in the heart area, as well as other signs that worry you, you should contact a cardiologist. It is he who makes the decision about the examination.

Heart ultrasound norms

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

• thickness of mitral valves up to 2 mm;
• diameter of the fibrous ring - 2.0-2.6 cm;
• The diameter of the mitral orifice is 2–3 cm.
• the area of ​​the mitral orifice is 4 - 6 cm2.
• the circumference of the left atrioventricular orifice is 6-9 cm;
• circumference of the left atrioventricular opening - 9.1-12 cm;
• active but smooth movement of the valves;
• smooth surface of the valves;
• the deflection of the leaflets into the cavity of the left atrium during systole is no more than 2 mm;
• the chordae are visible as thin, linear structures.

Some normal indicators:

• systolic opening of the valves is greater than mm;
• the area of ​​the aortic opening is 2 - 4 cm2.
• the doors are proportionally identical;
• full opening in systole, close well in diastole;
• aortic ring of medium uniform echogenicity;

Tricuspid (tricuspid) valve

• the area of ​​the valve opening is 6-7 cm2;
• the doors 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 thickness of the interventricular septum is 7-10 cm.
• myocardial mass in men is 135 g, myocardial mass 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 condition 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 device, on the skills, experience and acquired knowledge of the specialist.

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

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

Currently, modern and promising methods for examining patients using ultrasound waves have been developed:

1. Echo-CG 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.
2. Echo-CG using a transesophageal sensor. A one- or two-dimensional sensor is placed in the subject’s esophagus, with the help of which basic information about the organ is obtained.
3. Echo-CG using an intracoronary sensor. A high-frequency ultrasonic sensor is placed in the cavity of the vessel to be examined. Provides information about the lumen of the vessel and the condition of its walls.
4. Application of contrast when ultrasound examination. The image of the structures to be described is improved.
5. High resolution cardiac ultrasound. The increased resolution of the device makes it possible to obtain high-quality images.
6. M-mode anatomical. One-dimensional image with spatial rotation of the plane.

Methods of conducting research

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 considered more informative, since it can be used to assess the condition of the heart and large vessels from all possible angles.

Heart ultrasound can be supplemented with functional tests. The patient follows the suggested physical exercise, after or during which the result is deciphered: the doctor evaluates changes in the structures of the heart and its functional activity.

The study of the heart and large vessels is supplemented with Dopplerography. With its help, you can 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 to confirm the diagnosis.

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

1. Lethargy, the appearance or intensification of shortness of breath, fatigue.
2. A feeling of palpitations, which may be a sign of an irregular heart rhythm.
3. Extremities become cold.
4. The skin often turns pale.
5. Presence of congenital heart defect.
6. The child is gaining weight poorly or slowly.
7. The skin is bluish (lips, fingertips, ears and nasolabial triangle).
8. Presence of a heart murmur during a previous examination.
9. Purchased or birth defects, the presence of a valve prosthesis.
10. Trembling is clearly felt above the apex of the heart.
11. Any signs of heart failure (shortness of breath, edema, distal cyanosis).
12. Heart failure.
13. Palpation detectable “heart hump”.
14. Ultrasound of the heart is widely used to study the structure of organ tissue, its valve apparatus, detect fluid in the pericardial cavity (pericardial effusion), blood clots, and also to study the functional activity of the myocardium.

Diagnosis of the following diseases is impossible without ultrasound:

1. Different degrees of manifestation of ischemic disease (myocardial infarction and angina).
2. Inflammation of the cardiac membranes (endocarditis, myocarditis, pericarditis, cardiomyopathies).
3. All patients are indicated for diagnosis after a myocardial infarction.
4. For 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 abdominal cavity, brain, vascular diseases lower limbs).

Modern ultrasound diagnostic devices make it possible to obtain many quantitative indicators with which one can characterize the basic cardiac function - contraction. Even the early stages of decreased myocardial contractility can be identified by a good specialist and therapy can be started on time. And to assess the dynamics of the disease, ultrasound examination is performed repeatedly, which is also important for checking the correctness of treatment.

What does pre-study preparation include?

More often, the patient is prescribed a standard method - transthoracic, which does not require special preparation. The patient is only advised to maintain emotional calm, since anxiety or previous stress may affect the diagnostic results. For example, your heart rate increases. It is also not recommended to eat a large meal before a cardiac ultrasound.

The preparation before performing a transesophageal ultrasound of the heart is a little stricter. The patient should not eat 3 hours before the procedure, and for infants the study is carried out in between feedings.

Carrying out echocardiography

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

Such an examination requires technically sophisticated and high-quality equipment. Before attaching the sensors, 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. Modified acoustic waves return to the device through the same sensors. At this level, they are converted into electrical signals processed by an echocardiograph.

A change in the type of wave from an ultrasonic sensor is associated with changes in tissues and changes in their structure. The specialist receives a clear picture of the organ on the monitor screen, and 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 may be subcutaneous fat, chest bones, muscles or lung tissue.

Transesophageal echocardiography exists in a three-dimensional version, with the probe 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 small anatomical structures.

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

Fasting for 6 hours is mandatory before transesophageal echocardiography. The specialist does not delay 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 ​​may have age-related characteristics, and the indicators for men and women are also different.

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

Normal for the left ventricle:

1. The mass of its myocardium ranges from 135 to 182 grams in men, and from 95 to 141 grams in women.
2. Left ventricular myocardial mass index: for men from 71 to 94 grams per m², for women from 71 to 80.
3. 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.
4. The thickness of the walls of the left ventricle does not normally exceed 1.1 cm; increasing load leads to hypertrophy of muscle fibers, when the thickness can reach 1.4 cm or more.
5. Ejection fraction. Its norm is not lower than 55–60%. This is the volume of blood that the heart pumps out with each contraction. A decrease in this indicator indicates heart failure and blood stagnation.
6. Stroke volume. The norm from 60 to 100 ml also shows how much blood is ejected in one contraction.

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

The procedure lasts no more than 20 minutes, all data about the patient and his heart parameters are saved in electronic form, and a transcript is provided that is understandable to the cardiologist. The reliability of the technique reaches 90%, that is, the disease can be identified in the early stages and adequate treatment can begin.

Chapter 8. Mitral valve

General issues

Normal heart valves are so thin and flexible that they cannot be visualized using most diagnostic techniques. Echocardiography, which records differences in acoustic characteristics between connective tissue and blood, allows for detailed examination of the heart valves. 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 application of M-modal echocardiography is the recording of subtle valve movements, such as diastolic vibration of the anterior mitral valve leaflet in aortic regurgitation or mid-systolic closure of the aortic valve in hypertrophic cardiomyopathy.

Two-dimensional echocardiography provides a large observation area, however, the larger this area, the lower the resolution of the method; An important advantage of two-dimensional echocardiography is that this method can determine the extent of damage to the valve apparatus, for example, with sclerosis of the aortic valve.

Doppler echocardiography allows qualitative and quantitative assessment of blood flow through each of the heart valves. The main disadvantage of the method is the need to direct the ultrasound beam strictly along the flow to avoid distortion of the research results. However, the capabilities 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 a model of what a non-invasive method can provide.

With the widespread use of echocardiography, an increasing number of patients are undergoing surgical correction of valvular heart disease without prior cardiac catheterization. You can confidently rely on the results of echocardiographic assessment of the severity of the defect that led to severe hemodynamic disturbances. Only in two cases is an echocardiographic study not enough: 1) if there is a contradiction between clinical data and the results of an echocardiographic study; 2) if, when there is an undoubted need for surgical correction of the defect, other questions need to be clarified, most often - the presence or absence of pathology coronary arteries.

Normal mitral valve

Historically, the mitral valve was the first structure recognized by cardiac ultrasound. The orientation of the wide surface of the anterior mitral valve leaflet in relation to the chest makes it an ideal target for reflecting the ultrasound signal. The anterior leaflet of the mitral valve is very mobile, the ratio of the length of its edge to the base is large: this makes it possible to clearly examine 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) studies of the mitral valve. Doppler methods are very informative for diagnosing mitral valve pathology and for quantitative assessment of transmitral blood flow. The mitral valve is examined from several approaches: parasternal, apical and, less commonly, subcostal.

An M-modal study shows that the movement of a normal mitral valve reflects all phases of diastolic filling of the left ventricle (Fig. 2.3). Early maximum opening of the mitral valve (movement of the anterior leaflet towards the interventricular septum) corresponds to 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 anterior leaflet, inferior in amplitude. Closure of the mitral valve at the end of diastole occurs as a result of a slowdown in blood flow from the atrium and the onset of isometric contraction of the left ventricle.

Two-dimensional images of the mitral valve depend on the position from which the examination is performed. Thus, when parasternally examined along the short axis, the mitral valve is visible as an ovoid-shaped structure, and when examined along the long axis, it resembles opening and slamming doors, the anterior one of which is larger than the posterior one. 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 the apical approach. In general, a normal mitral valve should appear as a flexible bicuspid structure that opens enough to not impede ventricular filling and closes securely in systole without collapsing into the left atrium. The 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 related to the mitral valve are the chordae, papillary muscles, and the left atrioventricular annulus.

Doppler examination of a normal mitral valve reveals that the speed of blood flow through it can also be represented graphically by 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 access, which is used for Doppler examination of the mitral valve. Normally, the maximum velocity of 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. The anatomical manifestations of mitral stenosis include partial fusion of the commissures between the anterior and posterior leaflets and changes in the subvalvular apparatus - shortening of the chords. As a result, the area of ​​the mitral orifice 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 ​​the mitral orifice, so that the patient can be referred for surgery or balloon valvuloplasty without prior cardiac catheterization. Quantitative assessment of the severity of mitral stenosis can be made by three echocardiographic methods.

1. M-modal research. When M-modal examination of a patient with mitral stenosis, changes in the shape of the mitral valve movement are visible, expressed in prolongation of the time of its early closure (Fig. 8.1). Unidirectional diastolic movement of the tips of the mitral valve leaflets can be seen. The slope of the early diastolic covering of the anterior mitral valve leaflet (EF segment of the M-modal image of the mitral valve) allows recognizing mitral stenosis. An EF segment tilt of less than 10 mm/s (normally > 60 mm/s) while holding the breath indicates severe mitral stenosis. Currently, this sign is practically not used, since it is the least reliable way to determine 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 leaflet of the mitral valve is almost absent. RV - right ventricle, LV - left ventricle, PE - small effusion in the pericardial cavity, aML - anterior mitral valve leaflet, pML - posterior mitral valve leaflet.

2. Two-dimensional study. Normally, when examining the long axis of the left ventricle from the parasternal position, the anterior leaflet of the mitral valve during maximum valve opening in diastole looks like a continuation of the posterior wall of the aorta, whereas with 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 rounding of the valve occurs due to increased pressure on its unfixed part; An analogy would be inflating a sail. The area of ​​the mitral orifice should be measured in the parasternal position of the short axis of the left ventricle strictly at the level of the tips of the leaflets (Fig. 8.3). This planimetric method for assessing the severity of mitral stenosis is significantly more reliable than the M-modal method.

Figure 8.2. Mitral stenosis: parasternal position of the long axis of the left ventricle, diastole. Dome-shaped protrusion of the anterior mitral valve leaflet (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 area of ​​the mitral orifice. 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 diastolic pressure gradient between the atrium and ventricle is calculated from the maximum velocity. To calculate the area of ​​the mitral orifice, changes in this gradient are studied: the half-life of the pressure gradient is calculated (T 1/2), i.e., the time during which the maximum gradient is halved. Since the pressure gradient is proportional to the square of the blood flow velocity (?P=4V2), its half-life is equivalent to the time during which the maximum speed decreases by?2 (approx. 1.4) times. Hatle's work has empirically established that the pressure gradient half-life of 220 ms corresponds to a mitral orifice area of ​​1 cm 2 . The mitral valve area (MVA) is measured in constant wave mode from the apical access using the formula: [Mitral valve area (MVA, cm 2)] = 220/T 1/2.

Figure 8.4. Two cases of mitral stenosis: critical stenosis ( A) and mild stenosis ( IN). Continuous wave Doppler examination, apical access. The measurement of the mitral orifice area is based on the calculation of the half-life of the transmitral pressure gradient. The faster the speed of diastolic transmitral blood flow decreases during mitral stenosis, the larger the area of ​​the mitral orifice. MVA - mitral orifice area.

Of all three named methods, Doppler is the most reliable, and should be given preference over M-modal and two-dimensional determination of the area of ​​the mitral orifice. In table 10 shows a list of measurements that must be made during a Doppler examination of a patient with mitral stenosis.

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

Color Doppler scanning allows you to see the area of ​​​​acceleration of blood flow at the site of narrowing of the mitral opening (the so-called vena contracta) and the direction of diastolic flow in the left ventricle. Color scanning makes it possible to more accurately determine the spatial orientation of the stenotic jet, which helps to position the ultrasonic beam parallel to the flow during a constant-wave examination with an eccentric direction of the jet.

It must be remembered that the half-life of the pressure gradient depends not only on the area of ​​the mitral orifice, but also on cardiac output, left atrial pressure, and left ventricular compliance. The use of Doppler mitral orifice area measurement may lead to 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 decrease in transmitral blood flow velocity. Wrong result Measurements of the area of ​​the mitral orifice can be obtained from 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 the basis for calculating the area of ​​the mitral orifice at atrial fibrillation. We recommend using complexes corresponding to the largest RR interval (equal to at least 1000 ms) on the electrocardiogram monitor lead. Another source of error in measuring mitral orifice area may be the nonlinearity of the decrease in the velocity of diastolic transmitral blood flow (Fig. 8.5). In this case, it is also difficult to decide which part of the Doppler spectrum to select for measurements. Hatle recommends measuring the part of the spectrum corresponding to the longer half-life of the pressure gradient (and therefore the smaller mitral orifice area).

Figure 8.5. Mitral stenosis: continuous wave Doppler study from the apical approach. Nonlinearity of the descending part of the Doppler spectrum of the stenotic jet is a possible source of error in the Doppler determination of the area of ​​the mitral orifice. The figure shows possible options for calculating the area of ​​the mitral orifice; During cardiac catheterization, the area of ​​the mitral orifice was found to be 0.7 cm2.

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 left ventricular volumes (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 gradient of tricuspid regurgitation), it is possible in each individual case to judge the consequences of mitral stenosis and the risk of surgery.

Left ventricular afferent tract obstruction of non-rheumatic etiology

Mitral annulus calcification 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 detected in hypertrophic cardiomyopathy and kidney disease. Mitral annulus calcification can cause atrioventricular conduction disturbances. Typically, calcification of the mitral annulus is not accompanied by hemodynamically significant mitral regurgitation or stenosis (Fig. 8.6), but in rare cases, calcium infiltration of the entire mitral valve apparatus is so pronounced that it leads to mitral orifice obstruction, requiring surgical intervention. Doppler measurement of mitral orifice area - The best way identify and assess the severity of this rare complication of a common pathology.

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

Congenital defects accompanied by left ventricular outflow tract obstruction are rare in adults. These defects include the paravalvular mitral valve (the only papillary muscle), the supravalvular mitral annulus, and the triatrial heart (Fig. 8.7). Normal filling of the left ventricle can be prevented by left atrial myxoma. Carcinoid syndrome can develop in patients with metabolically active serotonin-producing tumors. This is a rare syndrome and most often involves isolated involvement of the right side of the heart (Fig. 10.3). Of 18 cases of this disease observed at the UCSF Echocardiography Laboratory, only two had left heart pathology, presumably associated with bronchogenic cancer.

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

Mitral regurgitation

Stenotic lesions of the mitral valve alter its diastolic motion and can be easily recognized using M-modal and two-dimensional echocardiography. Mitral valve pathology accompanied by mitral regurgitation is often subtle and more difficult to diagnose. This occurs because the movement of the mitral valve during systole is minimal, but if even a small part of the valve is not functioning correctly, severe mitral regurgitation occurs. However, 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 ​​the main etiological causes of mitral regurgitation. This table is based on the results of a study conducted in 1976-81. work in which data from echocardiography, angiography and surgical treatment in 173 patients with mitral regurgitation. Note that mitral valve prolapse turned out to be the leading cause of mitral regurgitation.

Table 11. Etiology of mitral regurgitation

Doppler examination plays a very important role in the diagnosis of mitral regurgitation of any severity. Best method search for mitral regurgitation - color Doppler scanning, as it is highly sensitive and does not require much time. Color Doppler scanning provides real-time information about mitral regurgitation. Although an idea of ​​the direction and depth of penetration of the regurgitant jet can be obtained in pulsed Doppler mode, color scanning is more reliable and technically simpler, especially with eccentric regurgitation. From the apical approach, mitral regurgitation appears as 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 color scanning method is close in sensitivity to X-ray contrast ventriculography.

About 40-60% healthy people have mitral regurgitation, the cause of which is insufficiency of the posteromedial commissure of the mitral valve, but this regurgitation is mild. The regurgitant jet penetrates the cavity of the left atrium by less than 2 cm. If the flow penetrates the cavity of the left atrium by more than half its length, reaches its posterior wall, enters the left atrial appendage or the pulmonary veins, then this indicates severe mitral failure. In Fig. 17.9, 17.10, 17.11 show mitral regurgitation of mild, moderate and high severity.

It should be borne in mind that when examining a dilated left atrium, there is a loss of color scanning sensitivity at great depths, and the severity of mitral regurgitation may be underestimated. The width of the developing jet at the valve level 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 using color scanning, then other Doppler methods are no longer used to search for it. However, if cardiac imaging is poor, color scanning may not be sensitive enough. In cases where transthoracic echocardiography is technically difficult and precise knowledge of the degree of mitral regurgitation is necessary, transesophageal echocardiography is indicated. Circumstances that make it difficult to assess 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. Figure 17.2 shows a transesophageal color Doppler image of mild mitral regurgitation in a patient with a dilated left atrium. Note that the choice of the correct gain led to clear visualization of “spontaneous contrast enhancement” of the left atrium, which indicates a technically correct study and eliminates underestimation of the degree of mitral regurgitation. In Fig. 17.13 shows minor mitral regurgitation, typical of a normally functioning prosthetic mitral valve. Rice. Figure 17.14 illustrates high-grade perivalvular regurgitation with a disc graft in the mitral position. In Fig. 17.15 you can see how the jet of mitral regurgitation enters the gigantic appendage of the left atrium.

If color scanning is not possible, the degree of mitral regurgitation is determined using a Doppler study in pulsed mode. The control volume is first set above the closure of the mitral valve leaflets into the left atrium. We recommend searching for mitral regurgitation in several positions, as it may have an eccentric direction. Careful Doppler examination with modern sensitive equipment often reveals early, low-intensity systolic signals that are consistent with 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 minor regurgitation is associated with the registration of the movement of a small number of red blood cells remaining at the end of diastole in the vestibule of the mitral orifice.

With hemodynamically significant mitral regurgitation, the intensity of the Doppler spectrum is significantly higher. However, due to the high velocity of the mitral regurgitation jet, caused by the large pressure gradient in systole between the ventricle and the atrium, a distortion of the Doppler spectrum occurs during pulsed Doppler studies and color scanning. The larger the volume of regurgitant blood, the denser the Doppler spectrum. Mapping the Doppler signal in pulsed mode consists of tracking the regurgitant jet, starting from the point of closure of the mitral valve leaflets and then as the control volume moves towards the upper 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 more severe it is. Continuous wave testing can accurately measure the maximum velocity of mitral regurgitation. However, this parameter is of little significance for assessing the severity of mitral regurgitation, since the maximum velocity reflects a large systolic pressure gradient between the left ventricle and the atrium, and it is large both in normal and pathological conditions. Only with very severe mitral regurgitation does the pressure in the left atrium during systole reach such a value that the maximum velocity of regurgitation decreases.

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

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 still consider it necessary to provide a method for calculating the regurgitant volume fraction (Table 12). Note that the condition for the applicability of the above formula is the absence of pathology of the aortic valve.

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

Indirect indicators of the severity of mitral regurgitation 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, pulmonary artery pressure increases, which can be assessed by measuring tricuspid regurgitation jet velocity.

Rheumatic damage to the mitral valve, as a rule, is expressed in its combined damage. Moreover, despite the presence of anatomical signs of rheumatic mitral stenosis, hemodynamically significant obstruction of the left ventricular afferent tract is often not detected. An echocardiographic study in M-modal and two-dimensional mode, even in the absence of hemodynamic changes, reveals signs of rheumatic lesions 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 lesions of the mitral valve and “pure” mitral insufficiency main role plays Doppler study.

Mitral valve prolapse was first described as a syndrome involving clinical, auscultatory and electrocardiographic changes in the mid-60s. Then it was shown that the mid-systolic click and murmur correlate with sagging of the mitral valve leaflets revealed by angiography. Awareness of the importance of this syndrome occurred in the early 70s, when it turned out that mitral valve prolapse has clear echocardiographic manifestations. And it was thanks to echocardiography that it became clear how widespread this syndrome is in the population. Two-dimensional echocardiography is of greatest importance in its diagnosis; Doppler studies complement it, making it possible to detect late systolic mitral regurgitation and determine the degree of its severity.

M-modal echocardiography gives about 40% of false-negative results if cardiac auscultation is taken as the diagnostic standard. Perhaps this low sensitivity method is associated with chest deformities; It has been shown that up to 75% of patients with mitral valve prolapse have radiological signs of bone deformities of the chest. Such deformations (eg pectus excavatum) can greatly complicate M-modal examination. However, what is much more important is not the interference with echocardiography, but the fact that skeletal changes indicate the systemic nature of the lesion connective tissue with 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 where they close. Apparent sagging of the valves into the left atrium does not create diagnostic problems. If the leaflets (or one leaflet) reach only to 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 mitral valve leaflets prolapse (arrows). It is clearly visible that the anterior leaflet 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 valve leaflet 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 displacement of the leaflet 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 two-chamber position. The addition of Doppler to M-modal and 2D was found to provide a specificity for diagnosing mitral valve prolapse of 93%. It appears, however, that the diagnosis of mitral valve prolapse cannot be based on Doppler studies. Given the prevalence of minor mitral regurgitation, this may 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 the leaflets, mitral valve prolapse is also accompanied by their thickening and deformation. Typically, the tips of the valves are the most affected and resemble the head of a pin with a dull surface. Thickening of the valves sometimes extends to the chords. Such changes in the valve apparatus are called its myxomatous degeneration (degeneration). The more deformed the valve, the higher the chances of detecting thickening of the endocardium of the interventricular septum in the place where it comes into contact with the excessively mobile anterior leaflet (similar local thickening of the endocardium of the interventricular septum is often found in hypertrophic cardiomyopathy). The more deformed the valves are, the higher the likelihood of clinical manifestations and complications of mitral valve prolapse: chest pain, cardiac arrhythmias, bacterial endocarditis, embolism and chordal rupture. In extreme cases, it is often impossible to distinguish prolapse from flailing leaflets and massive vegetations on the mitral valve (Fig. 8.10).

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

Bacterial endocarditis has become significantly better diagnosed with the advent of echocardiography; The range of information about this disease has expanded. The direct and main sign of bacterial endocarditis with damage to any valve is the detection of vegetations. By disrupting the integrity of the leaflets or chords, vegetations prevent complete closure of the valve and lead to mitral regurgitation. Vegetations look like formations on valves, usually very mobile. Detection of formations on the valves in the presence of clinical suspicion of bacterial endocarditis almost always allows for a correct diagnosis. However, myxomatous degeneration of the mitral valve, old, “healed” vegetations, and a ruptured cusp or chord can be mistaken for fresh vegetations. On the other hand, if echocardiographic examination is performed soon after the first appearance of clinical symptoms bacterial endocarditis, vegetation may not be detected. Small vegetations may remain undetected during echocardiographic examination due to insufficient resolution of the device, low signal-to-noise ratio, or due to insufficient qualifications or inattention of the echocardiographer. At the UCSF Echocardiography Laboratory, vegetations less than 5 mm in diameter were almost never recognized by M-modal examination. Two-dimensional examination in such cases usually revealed some changes in the valves, but not in the vegetation. At the same time, the M-modal study of patients with suspected bacterial endocarditis has the advantage over a two-dimensional study that it can detect a violation of the integrity of the valve, since it registers high-frequency systolic vibrations, invisible in a two-dimensional study due to lower temporal resolution.

It must be borne in mind that bacterial endocarditis usually affects the initially altered valves; therefore, it is almost impossible to recognize small-sized vegetations (less than 5 mm) against the background of existing valve changes. A good example of possible diagnostic difficulties is myxomatous mitral valve degeneration with chordal rupture (Fig. 8.10). In this case, a large, mobile, prolapsing, non-calcified formation is detected, giving systolic vibration. Diagnosis of such echocardiographic findings should be based on clinical picture And bacteriological research blood.

Most reliable method detection of vegetations - transesophageal echocardiography (Fig. 16.16). Its sensitivity for clinically confirmed bacterial endocarditis exceeds 90%. We recommend transesophageal echocardiography in all cases where vegetations are not detected during transthoracic examination, but there is a suspicion that the patient has bacterial endocarditis.