Cardiac aneurysm

Cardiac aneurysm is a bulging limited portion of the amended and thinned walls of one of the chambers of the heart (Fig). The reason aneurism of the heart is often myocardial infarction. Most often aneurism of the heart is localized in the area of the front wall and the apex of the left ventricle. There are acute and chronic heart aneurysm:
Acute cardiac aneurysm is developing in the first days of extensive myocardial infarction, when the influence of the increase in ventricular pressure during systole is bulging at the site of a softening wall of the heart. The clinical picture is characterized by the appearance of precordialgia pathological ripple in the III, IV intercostal space on the left of the sternum, pericardial friction noise, systolic noise (see), gallop rhythm (see Gallop rhythm). Acute cardiac aneurysm may be complicated by the rupture of walls with the subsequent tamponade heart. Chronic cardiac aneurysm is formed from acute when nekrotizirovannah plot is replaced by connective tissue scar, or in the late period of the development of extensive myocardial infarction, when the scar will make more of thickness of a wall and has a considerable period. Signs of chronic aneurism of the heart are: precordialgia ripple in the third and fourth intercostal space to the left of the sternum, above apical impulse, systolic murmur in cardiac Aneurysmthe area of the aneurysm of heart, "frozen" ECG (absence of dynamics of ECG changes, compared with its initial changes in myocardial infarction), x-ray data (decrease the amplitude of the contraction of the heart, often to education dumb zones on roentgenogram, paradoxical surge: during systole ventricle - bulging the area of the aneurysm, during diastole - indrawing). Forecast at aneurism of the heart serious. Surgical treatment. Prevention aneurism of the heart is early detection of myocardial infarction and adherence to the strictest regime of peace.
In Fig. - a large aneurysm of the front wall of the left ventricle, the top and interventricular septum. A dramatic thinning of the heart wall in the area of the aneurysm.

Cardiac aneurysm - expansion of one of the chambers of the heart due to limited bulging his thinning of the wall in the place of a sharp reduction or complete disappearance of her tone and contractility. Aneurism of the heart can be congenital or acquired, and the frequency of the latter prevail. Cause A. S. in most cases are myocardial infarction (see) and cardiosclerosis (see) of different origin (syphilis, septic, rheumatic and other).
Localization aneurysm depends on the place of previous myocardial infarction and is related to the type of coronary circulation, i.e. to the nature of branching main trunks coronary arteries. Most often formed aneurysm of the front wall and the apex of the left ventricle; septal aneurysm, the right ventricle and atrium are rare.
There are acute and chronic heart aneurysm. Acute A. S. develops in the first days after extensive myocardial infarction due to protrusion section muomalasi preserved layers of the wall of the heart due to the increased ventricular pressure during systole, and increased blood ventricular diastole. Acute A. S. may be complicated by the rupture of a wall with tamponade blood cavity of the heart shirts. The gap is often in the front wall, at least - in the back wall of the left ventricle. Breaks interventricular septum is comparatively rare, and breaks other parts of the heart are casuistry.
Chronic cardiac aneurysm is formed from acute as a result of displacement its walls with scar tissue, and can develop in the later period after the occurrence of myocardial infarction when nekrotizirovannah the area of the heart muscle is replaced by connective tissue cicatrice. If the scar will make more of thickness of a wall and has a considerable extent, under the influence of a blood pressure this site slowly stuck out. Chronic A. S. can be of three kinds: muscular, fibromuscular and fibrous. Muscle aneurysms develop in stark expressed dystrophic changes of the myocardium and are localized at the apex of the heart. The most frequent fibromuscular and fibrous aneurysm.
For chronic aneurism of the heart is characterized by a wall of blood clots that or only line the inside aneurismal cavity, or perform aneurysmal bag. In deep layers of thrombotic overlays found phenomenon of the organization; the surface layers, facing the cavity of the heart, are more recent thrombotic layers. Parietal blood clots formed in the very beginning of the formation of protrusion of the wall of the heart. Their existence is connected with changes in hemodynamic conditions and the blood coagulation system, as well as with reactive processes in the endocardium when it ischemia.
The mechanism of formation of A. S. is very complex and not completely understood. But found that education aneurysm contribute to hypertension and increased physical load.
In overwhelming majority of cases, the clinic staff observed postinfarction left ventricular aneurysm of heart. Form distinguish (Fig. 1) aneurysm diffuse, saclike, mushroom and so-called aneurysm at aneurysm.
The clinical course of A. S. can be divided into acute, subacute and chronic. Diagnosis of acute and subacute aneurysms heart difficult, as their clinical picture is often placed in the picture heavy, often prolonged myocardial infarction. However, there are a number of symptoms which allow to diagnose A. S.: phenomena heart failure early after myocardial infarction, thromboembolism, precardiac pathological ripple, "frozen" electrocardiogram.

Fig. 1. Cardiac aneurysm: 1 - diffuse; 2 - saccular; 3 - mushroom; 4 - aneurysm at aneurysm".

Clinical symptomatology chronic aneurysms heart polymorphic and often insufficiently pronounced, especially at small sizes aneurysmal bag and when aneurysm diffuse form, which is often difficult to distinguish from extensive scar attack. The most reliable sign of chronic A. S. should be considered precardiac pathological surge described A. N. The hired as a senior teacher. This symptom is observed in approximately half of patients with A. E., appears usually on the 2nd or 3rd day after myocardial infarction. In typical cases, the localization of pathological ripple does not match the place apex beat. This pulsation of the aneurysm and the apex of the heart occurs synchronously. Typically, incremental precardiac ripple is located in the III-IV intercostal space on the left of the sternum. Such localization is possible to separately identify the apical jerk.

Pathological ripple is best determined by the patient on the back or on the left side; however, it has the character of "rolling waves". In a separate location apical and aneurysmal push a specific "swing", named C. S. Nesterov symptom "rocker".
When localization aneurysm in the apex of the heart atypical precardiac ripple merges with apical impulse, in these cases they are difficult to distinguish. However, aneurysmal ripple on closer inspection has a peculiar character - it is more diffused, visible not only the eye, but a well is determined by palpation and graphically. Pathological ripple may diminish or disappear in connection with education in aneurysmal bag wall of blood clots.
Listening at aneurism of the heart murmurs are characterized by significant variability. They can be seen both in the acute period of education A. S., and chronic stages of its development.
Noise pericardial friction is determined usually when emerging acute A. S., i.e. in those cases when the pericardium cavity develops focal fibrinous pericarditis. Often bugged gallop rhythm.
A. L. Myasnikov considers typical for chronic A. S. systolic-diastolic murmur. This noise is well heard in the area of the aneurysm and has a sharp, high tone ("noise"), but is far not in all patients.
Electrocardiographic and vectorcardiographic researches allow to determine the degree of cardiac and localization A. S. However, even if according to ECG and vectorcardiography no extensive and of transmural myocardial lesions, there is no proof of the absence of the aneurysm. Vectorcardiography method has certain advantages over electrocardiographic, especially in clarifying localization aneurism of the heart in cases of multiple disorders of the myocardium. This method allows to identify the degree of left ventricular hypertrophy. Vectorcardiographic and electrocardiographic data may not be clear criteria to distinguish diffuse A. S. from saccular, i.e. to determine the extent bulging aneurysm.
In the diagnosis aneurism of the heart is very important radiological research method (see below).
Heart aneurysm must be differentiated from coelomic cyst pericardium, mitral heart disease, tumors and cysts of the mediastinum.
The prognosis for A. C. always serious. Most patients with postinfarction aneurysms are killed in the first 2-4 years after the development of the disease. Described observed long-term trends aneurism of the heart (over 15 years).
Among the causes leading to death when A. S. is ranked cardiovascular insufficiency, the second - embolism of the brain, the third re-myocardial infarction; less often (especially in chronic A. S.) cause of death is heart attack.
In view of the failure of the conservative therapy of patients with A. S. (especially saccular) surgical treatment (see Heart surgery).
Prevention A. S. is early detection of myocardial infarction and adherence to the strictest regime of peace and subsequent dynamic medical observation of patients.
Patients with myocardial infarction complicated by aneurysm of heart, require strict and long-sparing mode (6 months. and more) and for a long time lose their ability to work. A significant part of them needs to be translated into disability group I or II.