Heart aneurism

Description:

Heart aneurism — pathological local protrusion of a wall of heart in the place of its thinning. In most cases aneurism of heart is formed in a top of a left ventricle; especially allocate the aneurism of an interventricular partition eminating in a cavity of a right ventricle where pressure of blood is less, than in left.

Heart aneurism reasons:

In 95-97% of cases as the reason of aneurism of heart serves the extensive transmural myocardial infarction, preferential left ventricle. The vast majority of aneurisms is localized in the field of a front sidewall and a top of a left ventricle of heart; about 1% - in the field of the right auricle and a ventricle, an interventricular partition and a back wall of a left ventricle.
The massive myocardial infarction causes destruction of structures of a muscular wall of heart. Under the influence of force of intracardiac pressure the nekrotizirovanny wall of heart stretches and becomes thinner. The essential role in formation of aneurism belongs to the factors promoting increase in load of heart and chamber pressure – to an early rising, arterial hypertension, tachycardia, repeated heart attacks, the progressing heart failure. Development of chronic aneurism of heart etiologically and pathogenetic is connected with a postinfarkty cardiosclerosis. In this case under the influence of pressure of blood there is a protrusion of a wall of heart in the field of a connective tissue hem.
Much less than postinfarction aneurisms of heart, meet inborn, traumatic and infectious aneurisms. Traumatic aneurisms arise owing to the closed or open injuries of heart. It is possible to carry the postoperative aneurisms which are often arising after operations on correction of inborn heart diseases to the same group (Fallo's tetrad, a stenosis of a pulmonary trunk, etc.)
The heart aneurisms caused by infectious processes (syphilis, a bacterial endocarditis, tuberculosis, rheumatism) are very rare.

Classification:

On time of emergence distinguish acute, subacute and chronic aneurism of heart. Acute aneurism of heart forms during the period from 1 to 2 weeks from a myocardial infarction, subacute – within 3-8 weeks, chronic – over 8 weeks.
In the acute period the wall of aneurism is presented by the nekrotizirovanny site of a myocardium which under the influence of chamber pressure eminates knaruzh or in a ventricle cavity (at localization of aneurism in the field of an interventricular partition).
The wall of subacute aneurism of heart is formed by a reinforced endocardium with accumulation of fibroblasts and histiocytes, again formed reticular, collagenic and elastic fibers; on site the destroyed myocardial fibers connecting elements of various degree of a maturity are found.
Chronic aneurism of heart represents the fibrous bag which is microscopically consisting of three layers: endocardial, intramural and epicardial. In an endocardium of a wall of chronic aneurism of heart there are growths of the fibrous and hyalinized fabric. The wall of chronic aneurism of heart is thinned, sometimes its thickness does not exceed 2 mm. In a cavity of chronic aneurism of heart pristenochny blood clot of various size which can cover only an internal surface of an aneurysmal bag often is found or occupy almost all its volume. Friable pristenochny blood clots easily are exposed to fragmentation and are a potential source of risk of tromboembolic episodes.
Aneurisms of heart of three types meet: muscular, fibrous and fibromuscular. Usually aneurism of heart is single though 2-3 aneurisms at the same time can be found.
Aneurisms of heart can be true (are presented by three layers), false (form as a result of a rupture of a wall of a myocardium and are limited to pericardiac unions) and functional (are formed by the site of the viable myocardium with low contractility eminating in a ventricular systole).
Taking into account depth and extensiveness of defeat true aneurism of heart can be flat (diffusion), sacculate, fungoid and in the form of "aneurism in aneurism". At diffusion aneurism the contour of outside protrusion flat, flat, and from a cardial cavity is defined deepening in the form of a bowl. Sacculate aneurism of heart has a roundish convex wall and the wide basis. Fungoid aneurism is characterized by existence of big protrusion with rather narrow neck. The concept "aneurism in aneurism" designates the defect consisting of several protrusions concluded one in another: such aneurisms of heart have sharply thinned walls and are most inclined to a gap. At inspection diffusion aneurisms of heart come to light more often, is more rare - sacculate and are even more rare - fungoid and "aneurisms in aneurism".

Heart aneurism symptoms:

Clinical manifestations are defined by the aneurism sizes, its localization and complications connected with existence of aneurism. Acute aneurism of an interventricular partition is shown by symptoms of right ventricular heart failure (increase in a liver, hypostases, a hydrothorax, ascites). Patients with chronic aneurism of heart can not show any complaints for many years. However quite often chronic aneurism serves as the reason of heavy disturbances of a cordial rhythm, including ventricular tachycardia (see Arrhythmias). Complaints of patients with aneurism of a left ventricle of heart most often correspond to manifestations of its insufficiency: patients note an asthma and heartbeat at an exercise stress, and at big aneurism also at rest; attacks of cardiac asthma which can smooth out at accession of right ventricular insufficiency of heart are possible. In some cases the complaints connected with thromboembolisms of arteries of a brain, kidneys, spleens, extremities, etc. prevail.

Survey of area of a chest wall, adjacent to aneurism, at side lighting allows to find at acute aneurism of a front wall of a left ventricle a pathological pulsation in intercostal spaces. At auscultation systolic noise, quite often a cantering rhythm comes to light. The electrocardiography is of great importance for specification of the diagnosis of aneurism of heart. The so-called monophase curve — the stiffened electrocardiogram, long (more than 6 weeks) preservation of the raised ST segment is characteristic (as a rule, in combination with a deep tooth of Q decreasing at the usual course of a myocardial infarction since 3 — the 5th day of a disease). The sizes and a structure of aneurism can be determined by the echocardiography allowing to reveal dyskinesia (paradoxic movements) of a wall of a left ventricle and its thinning, a mural thrombosis.

Treatment of aneurism of heart:

In the preoperative period the patient with aneurism of heart appoints cardiac glycosides, anticoagulants (heparin subcutaneously), antihypertensives, an oxygen therapy, an oxygenobarotherapy.
Surgical treatment of acute and subacute aneurism of heart is shown in connection with bystry progressing of heart failure and threat of a rupture of an aneurysmal bag. At chronic aneurism of heart operation is made for prevention of risk of tromboembolic episodes and for the purpose of myocardium revascularization.
As palliative intervention resort to strengthening of a wall of aneurism by means of polymeric materials. To radical operations the resection of aneurism of a ventricle or an auricle (if necessary – treat with the subsequent reconstruction of a wall of a myocardium a patch), the septoplasty on Sacks (at aneurism of an interventricular partition).
At false or posttraumatic aneurism of heart sewing up of a cordial wall is made. In need of the additional revascularizing intervention in one step carry out an aneurism resection in combination with AKSh.
After a resection and an aneuroplasty of heart development of a syndrome of small emission, a repeated myocardial infarction, arrhythmias (a Bouveret's disease, a ciliary arrhythmia), insolvency of seams and bleeding, respiratory insufficiency, a renal failure, a thromboembolism of vessels of a brain is possible.