HEART (Latin cor, Greek cardia) — hollow fibromuscular body, to-ry, functioning as the pump, provides the movement of blood in the blood circulatory system.
- 1 HISTORY
- 2 The COMPARATIVE ANATOMY
- 3 The EMBRYOLOGY
- 4 ANATOMY
- 5 RADIOANATOMY
- 6 The HISTOLOGY
- 7 BIOCHEMISTRY
- 8 The PHYSIOLOGY
- 9 The PATHOLOGICAL ANATOMY
- 10 METHODS of INSPECTION
- 11 PATHOLOGY
- 12 Influence of pregnancy and childbirth on heart
- 13 PATHOLOGY of HEART AT CHILDREN
- 14 INFLUENCE of SPORTS ACTIVITIES ON HEART
- 15 Features of anesthesia at cardiac operations and special invasive methods of a research
Data on S.'s structure are available already in ancient manuscripts. In the papyrus «The secret book of the doctor» (17 — 11 centuries BC) described by G. Ebers there are sections «Heart», «Vessels of Heart». Hippocrates wrote about a muscular structure of heart. Aristotle believed that S. contains the air (pneuma) spreading on arteries. Erazistrat described valves C. and pointed to their value. K. Galen proved that arteries contain blood, but not air; in his book «About Purpose of Parts of a Human Body» there are data on an oval opening. Leonardo da Vinci allocated four cameras in S., described atrioventricular (atrioventricular) valves, their tendinous chords and papillary muscles. In detail A. Vezaly described a structure of heart. Especially important S. in studying were U. Garvey's researches which are summed up in the treatise «Anatomic Researches about the Movement of Heart and Blood at Animals» (1628) in Krom for the first time the correct information on S.'s work and on blood circulation was supplied. In the next years anatomists opened a number of formations of heart: B. Evstakhy found the special gate, JI in the mouth of the lower vena cava. Botallo — the channel connecting in the pre-natal period the left pulmonary artery to an aortic arch, R. Lower — fibrous rings of S. and an inter-venous hillock in the right auricle, A. Ch. Thebesius — the smallest veins of S. and the gate of a coronal sine, R. Vieussens — edge of an oval pole. Vyessan possesses valuable work about structure of Page (1715). In 1845 Ya. Purkinye published a research about the specific muscle fibers which are carrying out excitement according to S. (Purkinye's fiber) and by that laid the foundation for studying of its carrying-out system. In 1893 Gis described an atrioventricular band, in 1906 L. Ashoff together with S. Tawara — an atrioventricular (atrioventricular) node, in 1907. A. Keith together with Flek (M. W. Flack) — a sinus and atrial node. Detailed researches on embryology and S.'s anatomy were conducted by Yu. Tandler at the beginning of 20 century. The big contribution to studying of an innervation of S. was made by domestic scientists. F. G. Bidder in 1852 found accumulation of nervous cells (a node of the Bidder) in heart of a frog.
A. S. Dogel in 1897 — 1899 published results of researches of a structure nervous gangliyev S. and nerve terminations in it.
B. P. Vorobyov (1923) conducted the researches which became classical about neuroplexes of heart. B. I. Lavrentyev by means of an original eksperimentalnomorfologichesky method studied a sensitive innervation of Page.
The significant progress in studying of physiology of S. began two centuries later after opening of its pumping function by U. Garvey that was connected with creation by K. Ludwig Kimografa and development of methods of graphic registration by it fiziol. processes. The most important milestones in medicine are opening by brothers E. E. F. W. Weber and E. F. W. Weber of influence of a vagus nerve on heart (1845), opening by brothers I. F. Tsion and M. F. Tsion and studying by I. P. Pavlov of influence of a sympathetic nerve on S., identification of the humoral mechanism of transfer of nervous impulses on O. Levi's heart (1921); creation of techniques of studying of work of the isolated S. and development by I. P. Pavlov and N. Ya. Chistovich, and also E. Starlingom of heart-lung preparation; S.'s revival after the death of the person which is carried out by A. A. Kulyabko; S.'s change in an experiment on animals which is carried out by N. P. Sinitsyn and V. P. Demikhov; research Franc (O. Frank) and E. Starlingom of myogenetic mechanisms of self-control of S., and also regulation of cordial emission by A. Guyton; development of a technique electrocardiography (see).
For modern researches of physiology of a myocardium use of microelectrode technics was of great importance for studying of function of membranes of cells of a myocardium. These researches allowed to study mechanisms of the bioelectric phenomena arising in cells of a myocardium to-rye are the cornerstone of generation of rhythmic impulses of excitement of S. (automaticity C.), carrying out excitement in a myocardium, interfaces of excitement and reduction. Only in the second half of 20 century thanks to V. V. Larin's researches, E. I. Chazova, T. 3. Meerson, etc. mechanisms of regulation of the molecular processes proceeding in a myocardium and providing adaptation C. to various loadings were opened.
The main achievements in studying of pathology of S., creation of methods of its diagnosis and treatment belong to 19 and 20 centuries (see. Cardiology ).
The COMPARATIVE ANATOMY
the Closed vascular system with single-chamber S. appears at annlides. Vertebrata have a further development of S. and circulatory system.
Fishes have two-chamber S. consisting of an auricle (with the venous sine preceding it) and a ventricle, from to-rogo the arterial vessel — a ventral aorta departs (fig. 1, a). The page of fishes pumps over only a venous blood arriving from bodies. From S. blood on a ventral aorta comes to gills where it is enriched with oxygen.
Emergence of lungs in amphibiouses is followed by division of an auricle into two departments, and S. becomes three-chambered (fig. 1, b). In a ventricle the arterial blood arriving from the left auricle thanks to intra ventricular trabeculas accumulates in its left part, and the venous blood arriving from the right auricle — in the right part. In a middle part of a ventricle there is a mixing of an arterial and venous blood. The arterial cone departs from a ventricle, in Krom there are a spiral valve and a partition distributing blood on the arteries departing from a cone. Three pairs of arteries depart from it. The first couple — the skin and pulmonary arteries delivering a venous blood to lungs and skin (skin at amphibiouses takes part in gas exchange). From lungs blood is returned on pulmonary veins to the left auricle, forming a small circle of blood circulation. The second couple — aortic arches, to-rye bend around S. and connect in the dorsal aorta which is divided into the numerous arteries transporting the mixed blood to bodies and parts of a body. The third pair of arteries — sleepy; they bear an arterial blood to the head. Amphibiouses have front and back venas cava which are taking away blood from a body in the right auricle.
Page of reptiles three-chambered, but the ventricle is partially divided by an incomplete partition (fig. 1, c) therefore mixing of an arterial and venous blood happens only in small volume over this partition. However at reduction of a ventricle and reduction of its volume the partition completely divides a ventricle into two cameras. The arterial cone is reduced, and vessels leave S. separately. The right aortic arch begins from a left ventricle. It bends around S. on the right side and bears an arterial blood to the head and front extremities. The left aortic arch which is carrying out the mixed blood begins from a right ventricle over a partition. Bending around S. at the left, she unites to the right arch and, forming a dorsal aorta, supplies with blood other parts of a body. The pulmonary trunk beginning from a right ventricle carries out a venous blood to lungs.
At birds and mammal S. four-chamber with full division of flows of an arterial and venous blood (fig. 1, d). Birds have a reduction of the left aortic arch, and only two arteries depart from S.: aorta and pulmonary trunk.
At a germ of the person a bookmark C. occurs on the 3rd week of pre-natal development. Between the 16th and 21st days of development in cervical area over a vitellicle pair rudiments of S. in the form of two endocardial bags arising from a mesenchyma (see) are defined. From a visceral mesoderm (see) myoepicardial plates form, to-rye surround endocardial bags. In the subsequent both cordial bubbles are closed, their internal walls disappear therefore one two-layer cordial tube is formed (fig. 2, a).
From the layer of a cordial tube formed by a myoepicardial plate the epicardium and a myocardium, and from an endocardial layer — an endocardium form. At the same time the cordial tube moves caudally and it is located ventrally in a mesentery of a front gut (see. Pericardium ). The cordial tube connects to the developing blood vessels. Two umbilical veins bearing blood from a placenta and also two vitelline veins bringing blood from a vitellicle fall into its back department — a venous sine —. Two primary aortas depart from front department of a cordial tube, to-rye create 6 arterial arches (see. Aorta ).
S.'s development takes place from single-chamber to four-chamber. The cordial tube in the course of growth forms a S-shaped bend; the lower end of a tube moves up and kzad, and top end — down and kpered (fig. 2, b). At an embryo 2,15 mm long in a S-shaped tube distinguish four departments: a venous sine, in to-ry umbilical and vitelline veins, the venous department following it, behind venous — the arterial department bent in the form of a knee and an arterial trunk fall. During this period of S. it begins to be reduced.
Two-chamber S. is formed as a result of the expressed growth of venous and arterial departments, between to-rymi there is a deep banner. At an embryo 4,3 mm long both departments connect only by means of the narrow short channel called ushkovy, lying on site banners. At the same time two outgrowths — future ears of S. covering an arterial trunk are formed of the venous department which is the general primitive predserdyy. Both knees of arterial department of S. grow together with each other, the wall dividing them disappears and one general ventricle is created. Two general cardinal veins formed by merge of front and back cardinal veins fall into a venous sine, except umbilical and vitelline veins. At this stage of development there is only one big circle of blood circulation.
Three-chambered S. forms on the 4th week of development when on an inner surface of the general auricle there is a fold growing from top to bottom and forming at an embryo 5,5 mm long (at the end of the 4th week) the partition dividing the general auricle into two — right and left (fig. 2, c). However in a partition there is an opening (an oval window), through a cut blood from the right auricle passes into left. Two atrioventricular openings are formed of the ushkovy channel.
Four-chamber S. forms at an embryo 7,5 mm long (the 31st day of development). In the general ventricle the partition growing from below up dividing it into the right and left ventricles is formed. The general arterial trunk is also divided into two departments: the aorta and a pulmonary trunk connecting according to the left and right ventricles. At the same time there is a formation of semi-lunar valves of an aorta and a pulmonary trunk. In the subsequent of the right general cardinal vein the upper vena cava is formed (see. Venas cava ). The left general cardinal vein is exposed to a reduction and will be transformed to a coronal venous sine of heart. Disturbances of process of embryonic development lead to various patol. to states and inborn defects of S. (see. Heart diseases inborn ).
The page is in a front mediastinum in a pericardium between leaves of a mediastinal pleura. In relation to the centerline of a body of S. is located asymmetrically — apprx. 2/3 to the left of it and apprx. 1/3 — on the right. The longitudinal axis C. (from the middle of the basis to a top) goes slantwise from top to down, from right to left and behind forward. S.'s basis — its least mobile part, and a top — the most mobile. Situation C. happens various: cross, slanting or vertical. Vertical position meets at people with a narrow and long thorax, cross more often — at persons with a wide and short thorax. At delimitation of S. by means of percussion or a X-ray analysis on a front chest wall the frontal silhouette C. corresponding to its front surface and large vessels (fig. 3) is projected.
Distinguish the right, left and lower borders of Page. The right border of S., in an upper part corresponding to the right surface of an upper vena cava, passes from the upper edge of the II edge, at the place of its attachment to a breast, to the upper edge of the III edge, on 1 cm from the right edge of a breast to the right. The bottom of the right border corresponds to edge of the right auricle and passes from III to the V edge in the form of the arch remote from the right edge of a breast on 1,5 cm on the right. At the level of V edge the right border passes in lower, edges is formed by edge of the right and partially left ventricles and goes slantwise down and to the left, crossing a breast over the basis of a xiphoidal shoot, to an intercostal space at the left and further, crossing a cartilage of the VI edge, reaches the V intercostal space on 1,5 cm of a knutra from the sredneklyuchichny line (linea medioclavicu-laris). The left border is formed by an aortic arch, a pulmonary trunk, the left ear of S. and a left ventricle. It passes from bottom edge of the I left edge, at the place of its attachment to a breast, to bottom edge of the II edge (according to a projection * aortic arches), further at the level of II of intercostal space at 2 — 2,5 cm of knaruzha from the left edge of a breast (according to a pulmonary trunk). Continuation of the same line at the level of III edges corresponds to the left ear of Page. From bottom edge of the III edge, on 2 — 3 cm to the left from edge of a breast, the left border passes a convex knaruzha an arch to the V intercostal space on 1,5 — 2 cm of a knutra from the sredneklyuchichny line, corresponding to edge of a left ventricle.
Places of an exit of an aorta, a pulmonary trunk and their valves are projected at the level of III of an intercostal space: the mouth of an aorta — behind the left half of a breast *, and the mouth of a pulmonary trunk — at its left edge. Atrioventricular (atrioventricular) openings are projected on the line drawn from the place of an attachment to a breast of a cartilage of the V right edge to the place of an attachment of a cartilage of the III left edge. The projection of the right atrioventricular opening occupies the right half of this line, left — left.
The page is surrounded with a pericardium from all directions and directly does not adjoin to the bodies surrounding it. It has the irregular conical shape. Distinguish S.'s (basis cordis) basis directed up, kzad and to the right and a top (apex cordis) turned kpered, from top to bottom and to the left. In S.'s basis there are auricles (tsvetn. fig. 1). In front leave it aorta (see) and pulmonary trunk (see), in the right part fall into it an upper vena cava, in zadnenizhny — the lower vena cava, behind and at the left — the left pulmonary veins, and is slightly more right — the right pulmonary veins. Distinguish the following surfaces of S.: front, grudino-costal [facies sternocostalis (ant.)], lower, phrenic [facies diaphragmatica (inf.)], to-ruyu in clinic more often call back, and lateral, pulmonary [facies pulmo-nales (lat.)]. Allocate the right edge of S. (margo dext.), more acute, formed by generally right auricle and adjoining the right lung, and the left edge, more stupid, adjacent to the left lung. The front, grudinoreberny surface is formed on a bigger extent by a right ventricle and on smaller — a left ventricle and auricles (fig. 4). It prilezhit to a breast and cartilages of the left III—V edges, mostly adjoins to a mediastinal pleura and costal and mediastinal pleural sine.
To border between ventricles there corresponds the front interventricular furrow (sulcus interventricu-laris ant.), and between ventricles and auricles — a coronal furrow (sulcus coronarius). In a front interventricular furrow the front interventricular branch of the left coronary artery, a big vein of S., neuroplex and taking away limf, vessels is located; in a coronal furrow — the right coronary artery, • neuroplex and limf, vessels.
The lower, phrenic surface of S. is turned down and prilezhit to a diaphragm. It is formed by generally left ventricle, partially right ventricle and sites of the right and left auricles. On a phrenic surface both ventricles border with each other on a back interventricular furrow (sulcus interventricularis post.), in a cut pass a back interventricular branch right coronary (coronal, T.) arteries, average vein of S., nerves and limf, vessels. The back interventricular furrow near S.'s top connects to a front interventricular furrow, forming cutting of a top of S. (incisura apicis cordis).
The sizes C. are individually various. S.'s length of the adult fluctuates from 100 to 150 mm (more often than 120 — 130 mm), width in the basis of 80 — 110 mm (90 — 100 mm are more often) and the perednezadny size — 60 — 85 mm (65 — 70 mm are more often). S.'s weight averages 332 g (from 274 to 385 g) at men, women have 253 g (from 203 to 302 g). At newborn S. has rather big weight — 18 — 20 g (0,7 — 0,9% of body weight). By 6 months its weight concerning body weight decreases to 0,38%, and by 3 years increases to 0,52% again. Children till 1 year have length of Page 30 — 45 mm, width — 30 — 50 mm, the perednezadny size — 20 — 30 mm.
Heart consists of two auricles and two ventricles (tsvetn. fig. 2, 3). Right auricle (atrium dext.) has the irregular cubic shape. Capacity of the right auricle at the adult fluctuates within 100 — 140 ml, wall thickness makes 2 — 3 mm. Below it is reported with right ^желудочком by means of the right atrioventricular opening having the three-leaved valve. On the right the auricle forms a hollow shoot — the right ear (auricula dext.). The inner surface has it a number of the crests formed by bunches of edge muscles. On a lateral wall of an auricle edge muscles terminate, forming an eminence — a boundary crest (crista terminalis), to Krom on an outer surface there corresponds the boundary furrow (sulcus terminalis). Medial wall of an auricle — an interatrial partition (septum interatriale) — smooth. In its center there is a deepening — an oval pole (fossa ovalis). Its edges are thickened, especially in front and from above. The bottom of an oval pole is formed, as a rule, by two leaves of an endocardium. Height of a pole makes 18 — 22 mm, width — 17 — 21 mm. The fruit on site of an oval pole has an oval opening reporting both auricles. Quite often it remains by the time of the birth, causing mixing of an arterial and venous blood. Behind the upper vena cava, below — the lower vena cava above falls into the right auricle. The mouth of the lower vena cava is limited to the gate (valvula venae cavae inf.), representing a fold of an endocardium up to 10 mm wide. The gate of the lower vena cava at a fruit directs a stream of blood to an oval opening. Between mouths of venas cava the wall of the right auricle is stuck out and forms a sine of venas cava (sinus venarum cavarum). On an inner surface of an auricle between mouths of venas cava there is an eminence — an intervenous hillock (tuberculum intervenosum). The coronal sine of heart having the gate (valvula sinus coronarii) falls into a zadnenizhny part of an auricle.
Right ventricle (ventriculus dext.) in a form approaches the trihedral pyramid turned by the basis up. According to a form it has three walls: front, back and medial — an interventricular partition (septum interventriculare). Capacity of a right ventricle adult 150 — 240 ml, wall thickness have 5 — 7 mm. The weight of a right ventricle is 64 — 74 g.
In a right ventricle allocate two parts: actually the ventricle and an arterial cone (conus arteriosus) located in an upper left part of a ventricle and proceeding in a pulmonary trunk. An inner surface of a ventricle uneven at the expense of the fleshy trabeculas (trabeculae carneae) going in various directions. Trabeculas on an interventricular partition are very poorly expressed. Above in a right ventricle there are two openings supplied with valves: on the right and behind — the right atrioventricular opening (ostium atrio-ventriculare dext.), in front and at the left — an opening of a pulmonary trunk (ostium trunci pulmonalis). The right atrioventricular opening has the oval form; its longitudinal size makes 29 — 48 mm, cross — 21 — 46 mm. Three-leaved (right atrioventricular) the valve, as well as the mitral valve, consists of a fibrous ring (annulus fibrosus); shutters (cuspides) which are attached the basis to a fibrous ring (free edges of shutters are turned into a cavity of a ventricle); tendinous chords (chordae tendineae) going from free edges of shutters to a wall of a ventricle to papillary muscles or fleshy trabeculas; papillary muscles (mm. papillares), the ventricles (fig. 5) formed by the inner layer of a myocardium. Fibrous rings (right and left) — the dense educations limiting atrioventricular openings. They are connected with the corresponding fibrous triangles (trigona fibrosa dext. et sin.), lying in the basis of ventricles. In the right atrioventricular valve more often (in 56%) there are three shutters therefore it call three-leaved (valva atrioventri-cularis s. valva tricuspidalis). However the quantity of shutters can fluctuate from 2 to 6, and their bigger quantity meets at the big sizes of an atrioventricular opening. In the place of an attachment distinguish a lobby (cuspis ant.), back (cuspis post.) and septal (cuspis septalis) of a shutter. Tendinous chords in the form of several threads go from shutters to tops of papillary muscles or fleshy trabeculas. They are attached to shutters both on free edge, and on a lower surface (fig. 6, a).
In the location in a right ventricle distinguish three papillary muscles: lobby (m. papillaris ant.), back (n. papillaris post.) and septal (m. papillaris septalis). However the number of muscles, as well as shutters, can be various (from 2 to 9). A large number of papillary muscles happens at the increased quantity of shutters and a big atrioventricular opening.
The valve of a pulmonary trunk (valva trunci pulmonalis) interferes with a blood flow from a pulmonary trunk in a right ventricle. Diameter of an opening of a pulmonary trunk of 17 — 21 mm. The valve consists of 3 semilunar valves (valvulae semilunares): front, right and left. In the middle of each semilunar valve there are thickenings — small knots (noduli valvu-larum semilunarium) promoting more tight smykaniye of gates. Between gates and a wall of a pulmonary trunk alveoles of semilunar valves (lunulae valvularum semilunarium) form.
Left auricle (atrium sin.) a cylindrical forkhma, forms an outgrowth at the left — the left ear (auricula sin.). The Ekhmkost of the left auricle of 90 — 135 ml, wall thickness is 2 — 3 mm. An inner surface of walls of an auricle smooth, except for walls of an ear where there are rollers of edge muscles. On a back wall mouths of pulmonary veins are located (on two on the right and at the left). On an interatrial partition from the left auricle the gate of an oval opening (valvula foraminis ovalis) which grew together with a partition is noticeable. The left ear narrower and long, than right, it is delimited from an auricle by well-marked interception.
Left ventricle (ventriculus sin.) conical shape. Its capacity is from 130 to 220 ml, wall thickness is 11 — 14 mm. The weight of a left ventricle is 130 — 150 g. It has three walls — front, back and medial (an interventricular partition). Because of a zakruglennost of the left edge of S. front and back walls are unsharply differentiated. The site of a left ventricle, next to an aortic ostium, is called an arterial cone. The inner surface of a ventricle, except for a partition, has numerous fleshy trabeculas, thinner, than in a right ventricle (fig. 7). Above two openings are located: at the left and in front — left atrioventricular (ostium atrioventriculare sin.), on the right and behind — an aortic ostium (ostium aortae), to-rye, as well as in a right ventricle, valves have. The atrioventricular opening oval, its longitudinal size makes 23 — 37 mm, cross — 17 — 33 mm. Left atrioventricular valve (valva atrioventricularis sin.) has more often (in 60,9%) two shutters — front and back and in this regard is called two-fold, or mitral (valva bicuspidalis s. mitralis). The number of papillary muscles in a left ventricle fluctuates from 2 to 6, but more often (in 62,2%) two muscles — front and back meet (fig. 6, b).
The valve of an aorta is formed by three semilunar valves — back, right and left. An initial part of an aorta in the location of the valve is expanded (diameter reaches it 22 — 30 mm) and has three deepenings — sine of an aorta (sinus aortae).
At children under 6 years of S. most often of rounded shape, edge further becomes oval. S.'s basis is formed by two rather big auricles. S.'s walls thin, easily extensible. Papillary muscles are located further from S.'s top, than at adults, and tendinous threads therefore are shorter. By 7 years the trabecular network becomes multilayer and reaches the greatest development by 19 — 20 years.
To 2 — to 4-year age in connection with lowering of a diaphragm, increase in lung volume and a thorax, and also reduction of a pitchfork of-point gland C. gets slanting situation in a thorax and approaches its front wall. At children under 2 years the hl adjoins to a front chest wall. obr. the right ventricle taking the main part in formation of a cardiac impulse, and after 2-year age — and a part of the left l a rod.
Growth and differeytsirovka of a myocardium of the child happens stages, and considerable irregularity of growth of departments of Page is noted. Up to 1,5 — 2 years growth of auricles happens quicker, than ventricles, from 2 to 9 years — at identical speed to ventricles, and from 10 years — more slowly than ventricles. The left ventricle grows quicker right, especially up to 10 years. The ratio of thickness of walls of the left and right ventricles makes at the newborn 1,4:1, at the 4-month-old child 2:1, at 15-year-old — 2,76:1. At the age of 1 year the weight of a left ventricle is 2,5 times more, than right, and in the pubertal period — in Z,5 of time.
Innervation. A source of an innervation of S. is the cardiac plexus (plexus cardiacus) which is a part of the general chest vegetative texture — a chest aortal texture. Sources of formation of a cardiac plexus — the upper, average and lower cervical cardiac nerves arising respectively from upper, average cervical and cervicothoracic (star-shaped) nodes, the chest cardiac nerves going from chest nodes of sympathetic trunks and also top and bottom cervical and chest cordial branches of vagus nerves (see). Besides, in a cardiac plexus there are vegetative cordial nodes (ganglia cardiaca). The large node of this texture described by Vrisberg (N. of A. Wris-berg) and quite often called on his name, is located on a front surface of an aortic arch where there are also periaortal little bodies (corpora paraaortica). The cardiac plexus is located on front and back surfaces of an aortic arch (front and back parts of textures). Nerves depart from it, to-rye enter S. at a medial wall of an upper vena cava, in front of and behind the ascending part of an aorta, between an aorta and a pulmonary trunk, behind, at the left and to the right of a pulmonary trunk. On these nerves sympathetic fibers (generally postganglionic), preganglionic parasympathetic (from a vagus nerve) and sensitive approach S. (from sensitive nodes of a vagus nerve, and also from upper chest spinal nodes).
To respectively three covers of S. subepicardial, intramiokardialny and subendokar-dialny neuroplexes form. According to V. P. Vorobyov, distinguish six subepicardial textures: two lobbies and two the back, located respectively on front and back walls of ventricles, front and back textures of auricles (tsvetn. fig. 4 and 5). These textures contain numerous nodes of nervous cells (preferential parasympathetic). Nerves in a myocardium and to an endocardium depart from a subepicardial texture; they create the corresponding neuroplexes. The cholinergic and adrenergic neuroplexes which are distributed between fibers of a myocardium irrespective of capillaries are found. Density of neuroplexes in the right and left ventricles identical. Especially plentiful neuroplexes are available in walls of ears. Subendocardial neuroplex less dense; branches of nerves in shutters of atrioventricular valves and tendinous chords, and also in gates of the valve of an aorta and a pulmonary trunk depart from it. In all covers of S. there are many nerve terminations.
Blood supply it is carried out, as a rule, by two coronary arteries — left and right (aa. coronariae sin. et dext.), originating from the ascending part of an aorta within its bulb. By data A. M. Muracha (1966), the mouth of the left coronary artery is slightly more often (in 38,5%) is located in a back third of the left front sine of an aorta less often in a lobby (in 34,2%) or average (in 27,3%) thirds of a sine. Most often (in 72,8%) the mouth of the right coronary artery is in a back third of the right front sine less often in average (in 17,1%) or a lobby (in 10,1%) its thirds. Position of mouths of coronary arteries in relation to the upper edges of semilunar valves has specific features (see the Aorta). Diameter of mouths of the left coronary artery — from 3,5 to 4,8 mm (on average 4,2 mm), right — from 3,5 to 4,6 mm (on average apprx. 4 mm). In rare instances only one coronary artery is found, edges can after an otkhozhdeniye or be divided into two trunks — right and left, corresponding to similar coronary arteries, or, following their usual course, to vascularize at first one ventricle, and then another. Other branching of the only coronary artery is less often noted. The bigger quantity of coronary arteries (3 — 4) meets also seldom. The additional arteries of S. departing from arteries of a mediastinum, hl can be observed. obr. from bronchial arteries; they approach a thicket auricles.
The left coronary artery has diameter of 3,4 — 4,9 mm (more often than 3,9 mm). Length of the main trunk of an artery fluctuates from 6 to 34 mm, to a thicket makes 6 — 18 mm. On an otkhozhde-niya from an aorta she lays down in a coronal furrow and between a pulmonary trunk and the left ear usually (in 70%) is divided into two branches: lobby interventricular (of in-terventricularis ant.) and bending around (of circumflexus). Approximately in 30% of cases the left coronary artery can branch on three branches, is rare — on 4 — 5 branches.
Front interventricular branch to dia. 2,2 — 3,4 mm (3 mm are more often) go together with a big vein of S. in the furrow of the same name to S.'s top where anastomoses with a back interventricular branch of the right coronary artery; it can be covered with myocardial crossing points or even to pass intramu-ralno at a depth up to 2 — 5 mm. Depart from a front interventricular branch: branch of an arterial cone (of coni arteriosi), lateral branch (of lateralis), septal interventricular branches (rr. inter-ventriculares septales).
The bending-around branch to dia. 1,9 — 2,9 mm (2,6 mm are more often) pass in a coronal furrow and gives the following branches: anastomotic atrial (of atrialis anastomoticus), left regional (of marginalis sin.), intermediate atrial (of atrialis intermedius), back branch of a left ventricle (of ventriculi sinistri post.) and it is changeable — a branch of a sinus and atrial node (of nodi sinuatrialis), a branch of an atrioventricular node (of nodi atrioventricularis). The left coronary artery supplies with blood the left auricle, all lobby and the most part of a back wall of a left ventricle, a part of a front wall of a right ventricle, lobbies 2/3 interventricular partitions.
Right coronary artery to dia. 2,7 — 4,4 mm (on average 3,7 mm) depart from an aorta to the right and back, 'being located in the right part of a coronal furrow prior to the beginning of back interventricular where it passes into a back interventricular branch (r. interventricularis post.), S. which is going down to a top in the furrow of the same name. In a coronal furrow depart from the main trunk of an artery: branch of an arterial cone (r. coni arteriosi), branch of a sinus and atrial node (r. nodi sinuatrialis), right regional branch (r. marginalis dext.), intermediate atrial branch (r. atrialis intermedius). In 1/3 cases the right coronary artery is divided into the bending-around branch anastomosing with the bending-around branch of the left coronary artery and a back interventricular branch. The right coronary artery vascularizes the right auricle, a part of a lobby and all back wall of a right ventricle, the small site of a back wall of a left ventricle, an interatrial and back third of an interventricular partition.
Expressiveness of coronary arteries and a zone of their vascularization are changeable. Allocate three types of blood supply of S.: right coronal (60 — 84%) with dominance of a zone of supply of the right coronary artery (fig. 8, a), left coronal (meets, according to various data, approximately in 7 — 14%) dominance of a zone of supply of the left coronary artery (fig. 8, b) and uniform, or symmetric (in 10 — 28%), at Krom of a zone of branching of both arteries are approximately identical.
S.'s arteries branch on smaller arteries and further — on the arterioles which are distributed in all layers of a wall of body. Branches of arteriolar type, extensively branching, break up to an intramural capillary bed. Capillaries in a myocardium are usually oriented in the direction of muscle bundles, and within bunches — parallel to muscle fibers; they periodically form anastomotic loops. At children 1 capillary is the share approximately of 5 cardiomyocytes, and at adults this ratio makes 1:1. In a myocardium capillaries often create the venous sinusoids connected with
S.'s cavity venous graduates — so-called smallest veins (vv. cordis minimae). Between coronary arteries of different levels of division there is anastomosis providing development in necessary cases of collateral coronary circulation (see). The main anastomotic ways to S. are: 1) connections of the bending-around branch of the left coronary artery with right; 2) an anastomosis between septal interventricular branches of the right and left coronary arteries; 3) connection of front and back interventricular branches; 4) an anastomosis between arteries of epicardial arterial network, including an anastomosis of arteries of an epicardium and a pericardium; 5) an anastomosis between arteries of subendokardi-alny arterial network; 6) an anastomosis with arteries of an adventitia and wall of vessels. Data sovr. methods of coronary angiography confirm existence of a functional collateral blood-groove. At the same time contrasting of the right coronary artery and its branches after administration of contrast medium in the left coronary artery and contrasting of an arterial segment is observed places of full and subtotal arterial occlusion are lower. Collateral coronary circulation even at a considerable stenosis of coronary arteries is defined at coronary angiography more than in 60%.
Outflow of blood comes from veins of a wall of S. generally in a coronal sine (sinus coronarius) falling into the right auricle. To a lesser extent blood flows directly in the right auricle through front veins of S. (vv. cordis ant.) and the smallest veins.
The coronal sine forms from merge of the following veins: 1) the big vein of heart (v. cordis magna) collecting blood from front sites C. and going on a front interventricular furrow up and further S. turning to the left on a back surface where it directly passes into a coronal sine; 2) back vein of a left ventricle (v. post, ventriculi sin.), collecting blood from a back wall of a left ventricle; 3) slanting vein of the left auricle (v. obliqua atrii sin.), going from the left auricle; 4) the average vein of heart (v. cordis media) lying in a back interventricular furrow and draining adjacent departments of ventricles and an interventricular partition; 5) the small vein (v. cordis parva) passing in the right part of a coronal furrow and falling into an average vein of S. (fig. 9). The system of veins of a coronal sine carries out outflow of a venous blood from all departments of S. except for a front wall of a right ventricle, from a cut blood is taken away on front veins of Page. The smallest veins beginning from venous sinusoid of S. generally fall into the right half of Page. Intramural veins of S. form more developed bed in comparison with arterial. Therefore distribution of veins does not correspond to branching of intramural arteries. An anastomosis between S.'s veins is multiple and creates well reported bed between veins of different systems. An anastomosis in the field of S.'s top, between big and average veins is most expressed; on a front surface, between big, average, small and front veins; on a lower surface, between a back vein of a left ventricle and average veshsh S. Horosho developed an anastomosis between intramural veins, especially in a myocardium.
Lymph drainage it is carried out from an endocardium in vessels of a myocardium, and from it and an epicardium — in subepikar-dialny limf, vessels. There are three types of a lymph drainage from S.: right, left and uniform, S. corresponding to types of arterial blood supply (right coronal left coronal and symmetric). Networks limf, capillaries in an epicardium where there is a resorption of liquid from a pericardiac cavity are well developed. In an epicardium at adults limf. capillaries form two-layer epicardial capillary limf. network. Children have this network usually single-layer. Diameters limf. capillaries of superficial network of an epicardium from 0,015 to 0,1 mm, the sizes of loops — 0,15 X 0,15 — 0,18 X 0,25 mm, and deep — respectively 0,01 — 0,07 mm and 0,4 X 0,5 mm fluctuate. Capillary networks of auricles and right ventricle more rare, than left. From a deep capillary network of an epicardium form limf, vessels of the first order, to-rye, connecting among themselves and capillaries, form a vascular capillary network where the lymph from a superficial capillary network is drained. Limf, educations take place in an epicardium near circulatory capillaries and vessels, and arterial are located more deeply lymphatic, and venous — poverkhnostny them. Limf, vessels of the second, third and fourth orders go to a sub-epicardial layer and form subepicardial limf there, network, in to-ruyu vessels of a myocardium fall limf. «
In a myocardium limf, capillaries are located between muscle bundles. Near arteries and veins they create paravascular networks. Limf, capillaries in a myocardium to dia. 0,015 — 0,04 mm, connecting among themselves, form multilayer network with polygonal loops from 0,05 X 0,06 mm to 0,3 X 0,7 mm. Limf, capillaries of a myocardium form vessels of the first and seldom second order. Limf, capillaries to dia. 0,015 — 0,025 mm in an endocardium develop in network with the extended loops. Formed limf, vessels of the first order and capillaries fall into vessels of a myocardium. At senile age limf, capillaries are exposed to a reduction and therefore their network in all covers of S. becomes more rare, and loops of networks remain not closed.
Subepicardial limf, the vessels collecting a lymph from an epicardium, a myocardium and an endocardium form two ekstraorganny limf, a vessel (right and left), going to regional limf, nodes. Left ek-straorganny limf, vessel to dia. to 3 mm (sometimes a little limf, vessels) forms from vessels of the left half of S. and partially from right in a coronal furrow, at the place of an exit of a pulmonary trunk. Regional limf, nodes for left extra-organ limf, S.'s vessel are front and back mediastinal limf, nodes, in particular a node of an arterial sheaf (in 35,4%), lower tracheobronchial (in 24,6%), left bronchopulmonary (in 12,3%), front mediastinal nodes behind a back surface of a pulmonary trunk (in 10,7%), on a front surface of an aorta (in 10,7%) and right upper tracheobronchial limf. nodes (in 6,3%). Right ekstraorganny limf, the vessel is formed also in a coronal furrow at the place of an exit to the ascending part of an aorta, a thicket in the form of one trunk to dia. 0,8 — 3 mm. Nodes belong to regional limf, nodes for the right ekstraor-ganny vessel also mediastinal limf (limf, the nodes which are located at the place of an exit of the left subclavial artery, limf, a node of an arterial sheaf, right peritracheal limf, nodes and located on a front surface of the ascending aorta).
Multiprojective rentgenol. the research allows to study on a silhouette C. its major anatomic parts, a form, situation, borders, the sizes of body, and also the nature of the movements C. and its separate cameras.
Radiological distinguish three original positions of S. in a thorax: vertical, slanting and horizontal. At slanting situation C. the tilt angle of its longitudinal axis to a horizontal makes 43 — 48 °; at the same time the most part of S. is located to the left of a midline. At vertical position of S., a cut it is observed at persons with the asthenic constitution, the tilt angle of its longitudinal axis exceeds 48 ° (usually it makes 49 — 56 °); at the same time the line drawn through acanthas of vertebrae as if halves S. Horizontal position of S. is peculiar to persons with a short and wide thorax. At the same time the tilt angle of body makes 35 — 42 °; its most part is to the left of a midline, widely prilezhit to highly standing dome of a diaphragm.
At a usual rentgenol. a research the shadow of heart is homogeneous with well outlined contours in the form of arches. Their studying in different projections (a straight line, slanting and side) allows to reveal a X-ray anatomic picture C. and large vessels.
In a direct projection on the left contour four are visible, and on right — two arches (fig. 10, a). The first arch is formed by an aorta, the second at the left — a pulmonary trunk and partially left pulmonary artery, the third — the left ear, the fourth — a left ventricle. On the right the vascular arch is formed by the ascending part of an aorta, and a cordial arch — the right auricle. The most part of a front surface of S. is busy with a right ventricle. The basis of a ventricle corresponds to the coronal furrow going on a front surface of heart. In the same plane the right atrioventricular (three-leaved) valve is located. Closer the mitral valve is located to the bottom of the basis of an arterial cone, and it is slightly above and closer than a kpereda (on other projections) there is a valve of an aorta.
In the right (first) slanting projection the front contour of a shadow of S. and large vessels is formed by four arches: the ascending part of an aorta, a pulmonary trunk, output department of a right ventricle and a contour of a left ventricle. The back contour is formed by an upper vena cava, left and right auricles. The back contour of heart is separated from a backbone by a light strip — retrocardial space (fig. 10, b).
In the left (second) slanting projection the front contour of S. is formed at the top of the ascending part of an aorta, then an ear of the right auricle and below — a right ventricle. The upper arch on a back contour of S. is formed by the left auricle, lower — a left ventricle. Between a back contour of S. and a backbone there is a light strip — retrocardial space. The ascending part, an arch and the descending part of an aorta as if frame the light site called by an aortal window (fig. 10, c).
In the left side projection the front contour is formed by three arches: the ascending part of an aorta, a pulmonary trunk, an arterial cone of a right ventricle and a right ventricle. Between grudrshy and a right ventricle there is a narrow light strip — retrosternal space. The back contour is formed by arches: upper (the left auricle, the right auricle) and lower, created by a left ventricle (fig. 10, d).
At newborn S. on the roentgenogram has more roundish than at adults, a form, forming in a direct projection two, on the right at the left — three arches. The vascular shadow is often covered with a shadow of the-point gland increased a pitchfork. To features rentgenol. pictures C. at children of early age increase in a left ventricle, similar to its hypertrophy and dilatation at adults belongs a nek-swarm. S.'s top is raised over the left dome of a diaphragm, rounded off. S.'s waist is expressed due to retraction of an arch of the left auricle and increase in an arch of a left ventricle. On the left contour not four, but three arches (an aorta, a pulmonary artery, a left ventricle) are visible. The vascular bundle does not support limits of a backbone, sometimes the shadow of an upper vena cava is visible on the right. Quite often at children in the absence of S.'s pathology its so-called mitral configuration due to turn C. from right to left owing to increase in a right ventricle is defined. S.'s pulsations which are speeded up small amplitude. At children of advanced age the radioanatomy of heart almost completely corresponds that at adults.
S. consists of three covers: an epicardium (epicardium) — a visceral plate of a pericardium (see), a myocardium (myocardium) — a muscular coat, an endocardium (endocardium) — an internal cover. The epicardium is a serous cover (see. Serous covers). It consists of the lamina of the connecting fabric covered from a surface with a mesothelium.
The myocardium makes the ground mass of a wall of S. (tsvetn. fig. 1). The myocardium of ventricles is separated from a myocardium of auricles by fibrous rings, from to-rykh yarns of a myocardium begin. Their difficult orientation schematically can be presented as follows. The myocardium of auricles consists from superficial (cross) and deep (loop-shaped) layers; fibers of the last go almost vertically. The deep layer forms ring thickenings in mouths of large vessels. Besides, bunches of a myocardium extend in an outside cover of vessels out of borders of the Village. Loop-shaped bunches are stuck out in a cavity of auricles and ears (edge muscles). In a myocardium of ventricles it is conditionally possible to allocate outside, average and internal, or deep, layers. Periblasts of a myocardium of ventricles the general. Beginning from fibrous rings, bunches of a myocardium extend from top to down, in front — from right to left, behind — from left to right. At S.'s top they get into depth, forming a curl (vortex cordis) where take place from below up already in an opposite direction (lobbies — from left to right, back — from right to left) as a deep layer, create papillary muscles, fleshy trabeculas and are attached to fibrous rings. In general the course of fibers of outside and internal layers has an appearance of a rare spiral. The interlayer of bunches of a myocardium, to-rye also originate on fibrous rings, follows tsirkulyarno and turbinal, forming spiral loops as isolated for each ventricle, and the general for both. At the same time there is a uniform array of the bunches of a myocardium going in the specified directions which is not divided by the expressed connective tissue layers into separate layers.
In a myocardium there is a special system of the fibers having ability to carry out impulses from the nervous device to all muscular layers of S. and to coordinate the sequence of reduction of a wall of cameras C. These specialized muscle fibers make the carrying-out system of heart (see).
Tissue of a myocardium, keeping looking alike of cross-striped skeletal muscular tissue (see), significantly differs from it in a number of signs: the smaller sizes of muscle cells (cardiomyocytes) and a sarcomere, narrower strips, or disks I, existence in a cell of one kernel holding in a sarcoplasm central position, connection of cardiomyocytes consistently with each other on type the end in the end by means of inserted disks, the lack of strict parallelism during myofibrils which is sharply increased by quantity of the mitochondrions located parallel to myofibrils. The special saturation of cardiomyocytes mitochondrions reflects a high level of metabolism of the fabric having continuous activity. Cardiomyocytes have length of 50 — 120 microns, thickness of 15 — 17 microns and consist of a cellular cover (sarcolemma), a sarcoplasm and a kernel. In the sarcolemma covering a cardiomyocyte from all directions allocate two layers: outside, formed by homogeneous substance, and internal, being a plasma membrane. On this membrane there is a binding of the calcium ions arriving to sokratitelny elements of a cardiomyocyte. Between sarcolemmas of the next cells there is a longitudinal narrow intercellular crack. The inserted disks located between two cardiomyocytes are two plasma membranes divided by the interval of 8 — 25 nanometers filled intercellular h with substance. Existence of these inserted disks testifies to a cellular texture of a myocardium.
In a sarcoplasm of a cardiomyocyte there are sokratitelny elements — myofibrils and hyaloplasma (see), in a cut difficult organized membranes lie, mitochondrions (see), a sarcoplasmic reticulum (see. Muscular tissue), a lamellar complex of Golgi (see. Golgi complex ), lysosomes (see), microbodies, cytogranules. The arrangement of structural elements reflects functional specialization of its various departments in a sarcoplasm. In this regard allocate three zones of a sarcoplasm: perinuclear, myofibrillar and under - sarcolemmic. The perinuclear zone is located on 2 — 5 microns around a kernel and formed by a hyaloplasma, in a cut there are accumulations of mitochondrions, lysosomes, microbodies, cytogranules, vacuoles and tanks. The structure of this zone can be various depending on a functional condition of a cell. The myofibrillar zone forms the most part of a sarcoplasm. It includes myofibrils — actually 'sokratitelny elements, to-rye are located longwise and pass through all cell from one inserted disk to another. Throughout a myofibril alternation of various structures — the disks and strips making in total a sarcomere is noted, borders to-rogo are lines Z, or telophragmas. Length of a sarcomere makes 0,5 — 2 microns (on average 1,8 microns), and width apprx. 2,3 microns. Lines Z are the membranes passing across a cardiomyocyte both through myofibrils, and through the sarcoplasm dividing them, being fixed by a na'sarkolemma. In a sarcomere dark and ghost lines (disks) alternate. In a middle part of a sarcomere, making to. 80% of its length, are the dark strip of A (stria A) of a disk A (discus A) consisting of the anisotropic substance possessing double refraction. In the middle of a dark strip And there is a strip of N — the light zone (stria H, s. zona lucida), edges is crossed by a mesophragma (linea M), or a mesophragma (meso-phragma) dividing it, and also a dark strip And on two parts. At the same time the mesophragma is the membrane which is also taking up with a sarcolemma. It represents a steady element of a cross is-chercheynost of myofibrils and does not depend on their functional state. The strip And on both sides is adjoined by the ghost lines I (disk I) formed by isotropic substance and divided by the line Z into two half. On the parties from lines Z and M of a myofibril are crossed by sublines N.
One cardiomyocyte contains about 1000 myofibrils consisting of myofilaments — sokratitelny threads; the quantity to-rykh in bunches makes 200 — 1000. Allocate thin and thick myofilaments. Thick myofilaments to dia. 11 — 14 nanometers and length apprx. 1,5 microns lie in a strip And. Between the next thick myofilaments pass thin to dia. 4 nanometers and length apprx. 1 Micron which are attached to the line Z. Around each thick myofilament six thin are located. In a strip of N there are only thin, and in a strip only I thick myofilaments. Thick myofilaments contain preferential a myosin, and thin — actin. The period of existence of myofibrils before disintegration on average takes the moment of their synthesis apprx. 12 days.
The kernel of a cardiomyocyte lies is central and surrounded with a perinuclear zone of a sarcoplasm. The nuclear envelope is connected by thickness apprx. 10 nanometers with a cytoplasmic reticulum and lines Z and M. It has a time to dia. 30 — 80 nanometers, through to-rye are carried out transfer of the substances providing an active metabolism in a kernel.
Mitochondrions in cardiomyocytes are located quite densely between myofibrils, and also between them and a sarcolemma. They differ in a big variety of a form, quantity of cristas and density of a matrix. Length of mitochondrions is 0,3 — 2 microns, width is 1 microns. The ratio of mass of mitochondrions to the mass of myofibrils of a cardiomyocyte averages 1: 1 it is also connected with a functional condition of a cell. Mitochondrions carry out a role of the power device of a cardiomyocyte, in particular in them there is an oxidation fat to - t.
The sarcoplasmic reticulum consists from mesh and tubular elements, and also of the final tank. The tubules formed by membranes 4 — 5 nanometers thick pass longwise on the course of myofibrils and, anastomosing with each other, form a mesh element. In the field of the line Z (sometimes strips And) longitudinal tubules connect larger cross tubules, to-rye terminate in final tanks, the located sub-sarkolemmalno. Connect transport of the substances participating in exchange of a cell with a sarcoplasmic reticulum. In particular, it has ability to accumulate calcium ions and to give them to sokratitelny elements. The internal mesh device (Golgi's complex) in cardiomyocytes is developed poorly.
Lysosomes — roundish little bodies with a diameter up to 0,5 microns. They contain hydrolases (activity of acid phosphatase is especially high). By data C. de Dyuva (1963), function lpzosy is a fagirovaniye of the dying-off proteins. Vildental (To. Wildenthal, 1980) reported that the proteins which are a part of myofibrils break up under the influence of the enzymes of a sarcoplasm which are out of lysosomes. Other squirrels who are not participating in reduction break up at means of enzymes of lysosomes.
The endocardium covers S.'s cavity, including papillary muscles, tendinous chords, trabeculas and valves. In ventricles the endocardium is thinner, than in auricles. It, as well as an epicardium, consists of two layers: sub-endothelial and muscular and elastic, covered with an endothelium (see). The shutter of the valve C. represents a fold of an endocardium, in a cut there is a connective tissue layer.
the Myocardium in the major biokhimi-michesky and functional parameters is close to skeletal muscles, but cardiomyocytes it is less by the sizes and apprx. 30 — 40% of their volume occupy mitochondrions. In fabrics of the carrying-out system C. which was more adapted to anaerobic metabolism than a sokratitelny myocardium, mitochondrions borrow apprx. 10% of cellular volume, and a myofibril — apprx. 20%. Normal functioning of S. depends almost only on production of ATP in the oxidizing phosphorylation proceeding in mitochondrions (see) and demanding availability of molecular oxygen (the termination of intake of oxygen leads to bystry reduction of sokratitelny ability of a myocardium). For aerobic metabolism of S. the main power substrates are fatty acids (see), glucose (see), a lactate (see. Lactic acid), pyruvate (see. Pyruvic acid) and the ketone bodies (see) coming to cardiomyocytes from a blood plasma, and to a lesser extent — amino acids (see). In the presence of fat to - t and carbohydrates preferential power substrates for S. are fat to - you, on oxidation to-rykh it is used apprx. 70% of the oxygen consumed by S., other 30% are used generally for aerobic oxidation of carbohydrates. Transport of glucose in cardiomyocytes increases during the strengthening of glucose, in the presence of insulin (see), catecholamines (see), and also in the conditions of a hypoxia and decreases during the strengthening fat to - t. From a blood plasma only the free fat to-you (FFY) get into cardiomyocytes. Transport of SZhK in cardiomyocytes is carried out by passive diffusion after linkng with certain sites of a cellular membrane; it increases during the strengthening of SZhK and at increase in the relation SZhK/albumine. Lipoproteids (see) and triglycerides (see. Fats ) a blood plasma can be used in energy balance of S. only after their splitting to SZhK respectively a lipoproteid by a lipase (see) and lipases (see) an endothelium of capillaries. In cells of SZhK are activated with use of ATP (see. Adenozintrifosforiaya acid ) and education atsetil-KOA. The product of r-oxidation of SZhK atsetil-KOA is exposed to oxidation in a cycle tricarboxylic to - t (see. Tricarboxylic acids a cycle) to carbonic acid and water. Atsetil-KOA it is produced also as a result of oxidation of the pyruvate which is formed in the course of glycolysis (see) with participation of a piruvatdegidrogenazny complex of mitochondrions. In cardiomyocytes process of glycolysis almost at all the key stages experiences the inhibiting influence of system of oxidation of SZhK. Fat to - you inhibit transport of glucose, at their oxidation concentration of citrate increases and high concentration of the ATP and phosphocreatinine (FKR) inhibiting fosfofruktokinazny reaction are maintained (see Kinases), in mitochondrions the maintenance of NAD*N and atsetil-KOA, reducing the speed of piruvatdegidrogenazny reaction that leads to preferential oxidation in kardiomio-tspta of SZhK, but not glucose increases. The general speed of aerobic oxidation of SZhK and carbohydrates is connected with the speed of oxygen consumption, edges is the most important quantitative parameter of reactions of oxidizing metabolism and formation of ATP in S. (see biological oxidation). Speed of oxygen consumption is connected by linear relation with the work performed by S.: the relation of speed of oxygen consumption by a myocardium to the work of heart rate on systolic of the ABP (a measure of cardiac performance) at normal access of oxygen is a constant. At change of blood circulation from the state corresponding to physical rest of an organism to a state at the gross exercise stresses the speed of oxygen consumption of S. can change ranging from 50 to 300 mkg» atoms on 1 g of dry weight of fabric in 1 min. Content of is high-ergichesky phosphates — ATP and FKR (see Vysokoergichesky connections) in these conditions practically does not change since their quantity spent for S.'s reduction quickly is filled due to their synthesis in mitochondrions.
As well as in a skeletal muscle, reduction of myofibrils of S. is provided due to energy of ATP, edges will be transformed to mechanical work at interaction of a myosin (see. Muscular tissue) of thick protofibrils (myofilaments) with actin of thin protofibrils. S.'s myosin is close on a structure and structure to a myosin of skeletal muscles, but contains only two types of light chains about a pier. it is powerful (weighing) 18 500 and 25 000. Interaction of actin and a myosin is regulated by Sa2+-chuvstvi-telnym troponin-tropomiozino-vym the complex located on thin protofibrils. The maximum activation of the sokratitelny device of cardiomyocytes is reached at concentration of free ions of Sa2 + 10“ 5 — 10“ 4 mol, edges at relaxation of a myocardium 7 mol decrease to 10 ". Concentration of free ions of Sa2 + is controlled by the processes of electromechanical communication connecting depolarization of a cellular membrane at distribution of action potential with activation of reduction in result of binding of Sa2 + with troponiny (see. Muscular contraction).
Transport of energy in cardiomyocytes is important especially since ATP and ADF in them are distributed between different cellular structures. The maintenance of ADF in a myocardium averages 0,5 — 1,0 µmol on 1 g of crude fabric, but only 0,02 — 0,05 µmol are in cytoplasm in a stand-at-ease, and the main part of ADF is connected with actin and with components of a cell. From the general content of ATP only its small part is available to direct and bystry use at reduction, edges it is localized in myofibrils and about membranes (local pools of ATP) therefore change of a functional condition of cardiomyocytes is not followed by noticeable changes in the general content of ATP in cells. Communication between various pools of ATP is carried out through FKR with participation of a creatine kinase (see), edges catalyzes reaction of ATP - f-creatine «± FKR - J-ADF, supporting by that a ratio of ATP: ADF on a fixed level.
Development of an acute heart failure at ischemia and a myocardial infarction is connected with metabolic disturbances. At partial or complete cessation of access of oxygen to cells decreases or completely oxidation of SZhK stops and anaerobic glycolysis and a glycogenolysis with formation of a lactate are activated. However these processes do not provide energy production in the quantity necessary for reduction. At the first, reversible stage of ischemic damage of cardiomyocytes bystry reduction of contractility happens to reduction of maintenance of FKR at less considerable changes of content of ATP. Acidulation of the intracellular environment as a result of accumulation of a lactate is one of the factors aggravating development of ischemic damage. In the subsequent there is a gradual reduction of content of ATP, temporary increase in quantity of ADF and AMF and then splitting of adenylic nucleotides (see Adenozin-fosforpye of acid) to inosine and hypoxanthine. At the same time damages begin to accept irreversible character that is connected with destructive changes, first of all, in a sarcolemmic membrane, increase in permeability leads a cut to disturbance of ionic balance in cells and their overload calcium. At this stage observe swelling and destruction of mitochondrions. Reoksigenization at this stage instead of improvement of a condition of a myocardium leads to aggravation and the accelerated development of destructive changes. Disturbance of a sarcolemmic membrane is followed by emission in a blood stream of components of cytoplasm, including cytoplasmatic enzymes what the enzimodiagnostika (see Enzymes) a myocardial infarction is based on. Total disappearance of a pool of adenylic nucleotides in myofibrils leads to development of a contracture and to destruction of myofibrils.
S.'s Activity as pump is the main source of mechanical motion energy of blood in small and big circles of blood circulation (see) thanks to what the continuity of a metabolism and energy in an organism is supported. Ensuring this activity is connected with specific fiziol. functions of separate structures of S. promoting transformation of chemical energy to mechanical energy of reduction of a myocardium of auricles and ventricles in a certain rhythm. Respectively, except property of contractility, important objects fiziol. researches are such properties C. as the automaticity (see), excitability (see), conductivity, a refrakternost, etc.
The myocardium has excitability, i.e. ability under the influence of irritants to come to a condition of excitement (see). Impulses of excitement periodically arise in S. under the influence of the processes proceeding in him. This phenomenon received the name of the automaticity.
The specific muscular tissue creating a sinus and atrial node and the carrying-out system of heart (see) has ability to the automaticity. On membranes of cells of specific muscles of S. the electric impulses passing to a working myocardium and causing it reductions arise.
Membranes of cardiomyocytes, as well as any excitable fabric, are polarized. At rest the outer surface of their membranes is loaded positively, internal — is negative. The potential difference arises owing to different concentration of Na + and K+ on a surface and in a cell, and also directional permeability of a membrane for these ions (see Membranes biological). At rest the membrane is almost impenetrable for Na + and partially a pronitsayema for K+, to-ry under the influence of process of diffusion leaves a cell, increasing positive charge by surfaces of a membrane. At the same time the inner surface of a membrane gets a negative charge. The potential difference at rest — the so-called rest potential of a membrane — makes 60 — 80 mV in a myocardium of hematothermal animals. However the cells of specific muscles having ability to the automaticity differ in the fact that at rest, i.e. without any external influences, their membrane potential does not remain to constants. Unlike fibers of a sokratitelny myocardium a membrane of these cells in a diastole of a pronitsayem for Na+. Owing to movement of these ions in a cell and simultaneous decrease in permeability for K+ there is a gradual reduction of positive charge by surfaces of a membrane — so-called slow diastolic depolarization develops. When the level of rest potential decreases in comparison with initial approximately by 20 mV, there is a sharp increase in permeability of a membrane for Na+ therefore Na + as avalanche arrives in a cell, causing depolarization of a membrane — there is an action potential (see Bioelectric potential). This process equally takes place in cells of specific muscles and working myocardium. Due to the receipt of ions of Na + reversion of potential develops in a cell on a surface of a membrane, i.e. the outer surface of a membrane gets negative electric charge. Amplitude of peak of action potential at the same time exceeds the size of rest potential and reaches 100 millivolts and more. Action potential depolarizes membranes of the next cells therefore they generate own action potentials — there is a distribution of process of excitement on cells of a myocardium.
The site, in Krom the impulses leading to S.'s reduction automatically arise, call a pacemaker, or a pacemaker (see). In normal conditions it is the sinus and atrial node.
Feature of the carrying-out system of auricles and ventricles is ability of each of its cells in case of need independently to generate impulses of excitement, i.e. it, as well as a sinus atrial node, possesses the automaticity (see. The carrying-out system of heart). In S. there is a so-called gradient of the automaticity which is expressed in the decreasing ability to the automaticity of various sites of the carrying-out system in process of removal them from a sinus and atrial node. Cells of a sinus and atrial node of the person at rest spontaneously generate rhythmic impulses of excitement with a frequency of 60 — 80 imp / mines, a cell of an atrioventricular node — with a frequency of 40 — 50 imp / mines, a cell of a bunch of Grs — with a frequency of 30 — 40 imp / mines, and Purkinye's fiber — frequency apprx. 20 imp / min. In usual conditions the automaticity of all sites of the carrying-out system is suppressed with the frequent impulses arriving to them from a sinus and atrial node, but in case of defeat of the last a pacemaker the department of the carrying-out system located become hierarchically lower — the atrioventricular node providing the frequency of reductions of S. apprx. 40 — 50 in 1 min. can. In rare instances S.'s pathologies a pacemaker become Purkinye's fibers.
Having arisen in a sinus and atrial node, excitement on special intra atrial conduction paths — to Bakhmann's bunch, etc., and also diffuzno extends on a myocardium of auricles and reaches an atrioventricular node where there is a delay in carrying out excitement providing the necessary sequence of reductions of auricles and ventricles; thanks to this delay blood during reduction of auricles fills a cavity still of the weakened ventricles. From an atrioventricular node excitement on a ventriculonector and Purkinye's fibers — the carrying-out system of ventricles — extends to fibers of a sokratitelny myocardium. In a myocardium of auricles and ventricles the speed of carrying out excitement makes 0,9 — 1,0 m/s, in fibers of an atrioventricular node — 0,05 m/s, a ventriculonector — 1 — 1,5 m/s, Purkinye's fibers — 3 m/s.
Bystry carrying out through Purkinye's fibers provides almost simultaneous excitement of various sites of a myocardium of ventricles that increases the power of reduction of heart and overall performance of ventricles on forcing of blood. Time of coverage of a surface of ventricles excitement makes 10 — 15 ms.
Electric potentials, emergence to-rykh it is connected with spread of activation on heart, it is possible to register by means of the electrodes imposed on a body surface (see Elektrokardiografiya). For a wedge, practicians there was useful a vektorelektro-cardiography (see Vektorkardiogra-fiya) — two-coordinate representation in mutually perpendicular directions of signals of two different assignments of electric activity of Page.
Action potentials of membranes of heart fibers represent the releaser including a series of the intracellular processes interfacing excitement to reduction of myofibrils.
Rhythmic reductions of S. never pass in tetanic (see the Tetanus), at to-rykh its delivery function would stop. Emergence of tetanic reductions of S. is impossible thanks to existence at all its fibers of a refractory phase (see Refrakter-nost), edges in S. are much longer, than in skeletal muscles and nerve fibrils.
At reduction of a muscle, century of t. h a myocardium, length of octynic and mio-zinovy threads of a sarcomere — the main sokratitelny unit of muscular tissue (see) — does not change, shortening of muscle fiber is reached at the expense of a vdviganiye of octynic threads between miozinovy. Capture and pro-moving of octynic thread is carried out by means of vesloobrazny movements of crossbridges — the acting sites of miozinovy thread. At relaxation of a muscle octynic threads are removed back and hold former position in relation to threads of a myosin.
Aktinovy threads consist of chains of molecules of protein of actin, on a surface to-rykh there are fine ends from protein of the tropomyosine blocking the centers of interaction of actin with a myosin. Tropomyosine forms a complex with protein tropo-niny, the possessing high affinity to Sa2+. Miozinovy threads are formed by proteins — light and heavy meromyosin, the last creates crossbridges and has ATF-aznoy activity.
Process of reduction of a myocardium is started by Sa2+, to-ry arrives to sokratitelny proteins from tanks of a sarcoplasmic reticulum (see. Muscular tissue) under the influence of an impulse of excitement. Sa2 + communicates troioniny that causes change of a spatial relationship troponin-tropomio-zinovogo a complex on octynic thread, removing brake action it on active centers of actin. The association of actin with a myosin — the formation of actomyosin identified with reduction and the splitting of ATP releasing energy for sliding of octynic threads results.
Process of relaxation of a myocardium results from removal of calcium ions from a troponin under the influence of repolarization of a membrane and binding by their sarcoplasmic reticulum, and also owing to «pumping out» of calcium ions pumps of cellular membranes in intercellular liquid.
At repeated electric irritations of the stopped S. there is gradual strengthening of ions of Sa ++ in a cell owing to what force of each subsequent reduction gradually increases until reductions do not reach the maximum size. This gradual increase of force of reductions received the name «Bowe-dicha ladder». The possibility of calling of reductions in response to
S.'s irritation is used by electric current in modern methods of normalization of a rhythm of S. by means of portable electrostimulators (see Cardiostimulation).
The page forces blood in vascular system thanks to periodic consecutive reduction of muscle cells of auricles and ventricles. Due to the existence of interatrial conduction paths and general layers of a myocardium at the right and left auricles, and also simultaneous arrival of excitement to cells of a myocardium of ventricles on the right and left legs of a ventriculonector and Purkinye's fibers reduction of both auricles, and then both ventricles is carried out practically at the same time.
Inside S. owing to existence of valves blood moves only in one direction: in a phase of a diastole — from auricles in ventricles, in a phase of a ventricular systole — from a right ventricle in a pulmonary trunk, from left — in an aorta. Zakhlopyvaniye and opening of valves C. is connected with change of the direction of a pressure gradient between ventricles and auricles (for mitral and three-leaved valves), between ventricles and vessels departing from them (for semi-lunar valves of an aorta and a pulmonary trunk) in a phase of a systole and a diastole of ventricles (see. Intracardiac pressure, Blood circulation).
In a phase of a diastole of S. pressure in its cameras is close to zero; apprx. 2/3 volumes of the blood coming to ventricles in a phase of a diastole inflows in connection with the positive pressure of blood in noncardiac veins and 1/3 it is pumped up in ventricles in a phase of an auricular systole. Auricles are the tank for the inflowing blood which is easily changing the capacity thanks to notto big thickness of their walls. The volume of this tank can increase in connection with existence of additional tanks — ears of the auricles (reminding the tobacco pouches capable at a raspravleniya to contain the considerable volume of blood).
Changes of pressure in cameras C. and the vessels departing from it cause the movement of valves C., movement of blood that together with change of tension of walls of S. is followed by sound phenomena, in particular formation of cardiac sounds (see).
At each reduction of S. the right and left ventricles expel respectively in a pulmonary trunk and an aorta on 60 — 70 ml of blood — systolic, or shock, the volume of blood. The amount of blood forced by S. in an aorta within 1 min. is called the minute volume of blood (MO), and the relation of MO to the surface area of a body — cardiac index. From MO values and the average pressure of blood in an aorta external work of S. is defined, makes edges in the conditions of physical rest at the person 7 — 11 kgm, and at hard physical activity increases to 80 kgm.
The energy which is marked out at S.'s activity by 4 times exceeds that, to-ruyu it is possible to determine by calculations of size of its external work. In comparison with other bodies, except for a cerebral cortex, S. most intensively absorbs oxygen of blood. Therefore general air hunger (naira., at rise on height) and interruptions in supply of a myocardium with oxygen (at disturbances of coronary circulation) quickly break
S. U activity men the sizes C. on average 10 — 15% more, than at women, and the heart rate 10 — 15% lower. Cardiac index at women is 7 — 10% less, than at men.
With age the size of cardiac index decreases (on a nek-eye to data — on average by 25 ml/min./sq.m a year).
Decrease in regenerator opportunities of an organism and intensity of exchange processes at advanced age affects
S.'s activity and reduces adaptation it to intensive loadings. Besides, S.'s work is burdened owing to increase in rigidity of walls of arteries, napr, at atherosclerosis when reduction of their distensibility demands increase in power of systolic reduction of a myocardium of ventricles.
Features of function C. at children are closely connected from it morfol. features and age dynamics. In regulation of activity of S. of newborns the dominating role is played by a sympathetic nervous system that along with a high metabolism causes the high frequency of cordial reductions. In process of increase in S.'s regulation in a role of a vagus nerve pulse rate gradually decreases with age. At newborns it makes 120 — 140 in 1 min., aged month — 130 — 135, in 1 year — 120 — 125, in 2 — 4 years — 100 — 115, in 5 — 7 years — 85 — 100, in 8 — 11 years — 80 — 85, in 12 — 15 years — 70 — 80 in 1 min. The number of cordial reductions at children of the same age is subject to individual fluctuations and depends on temperature, meal, time of day, an emotional state, etc. At healthy children sinus (respiratory) arrhythmia — vagal pulse, especially expressed at children of preschool and school age is often observed.
The size of shock and minute volumes of S. increases with age (see Blood circulation, features at children), at the same time the stroke output changes more considerably, than minute since with age rate of reductions of S. is slowed down. The relation of minute volume of S. to the body weight of the child decreases with age, i.e. this relation characterizing the needs of an organism for oxygen is higher at newborns and at children of chest age. Distinctions of shock and minute volumes of S. depending on a sex of the child come to light after 10 years.
Regulation of action of the heart
Adaptation of activity of S. to the changing requirements of an organism happens to the help of regulatory mechanisms, a part to-rykh is inherent in S. K to endocardiac regulatory mechanisms carry intracellular mechanisms of regulation, regulation of intercellular interactions and endocardiac nervous peripheral reflexes. Also noncardiac nervous and humoral control of cordial activity takes place. All forms of regulation of action of the heart provide its adequacy to the needs of an organism for blood supply.
Intracellular level of regulation of work of S. consists in ability of cardiomyocytes to synthesize various proteins. Speed of synthesis is regulated in a cell by the autoregulyatorny mechanism supporting the level of reproduction of this protein according to intensity of its destruction. Believe that such regulation at the highest metaphytes is carried out thanks to interaction of cardiomyocytes with connective tissue cells.
In addition to regulation of protein synthesis, intracellular mechanisms provide a possibility of change of intensity of activity of S. according to amount of the blood inflowing to it. The strengthened inflow of blood causes more severe stretching of cells of a myocardium at the time of a diastole. It leads to the fact that octynic threads of each myofibril more move forward from intervals between miozinovy threads. There is a growth of number of crossbridges, i.e. the sites providing compound of octynic and miozinovy threads at the time of reduction. As a result each myofibril is reduced the stronger, the more was stretched during a diastole, and heart in general is reduced the more intensively, than more blood inflowed to it during a diastole. This pattern received the name of the law of Frank — Starlinga by name the scientists who opened it (see Starlinga the law).
Regulation of intercellular interactions in a myocardium is connected with function of neksus — the inserted disks providing transfer of excitement from a cell on a cell. Disturbance of intercellular interactions can lead to the expressed non-simultaneous excitement of separate cells of a myocardium and to disturbance of its sokratitelny function, and also a rhythm of Page.
Intraorganic mechanisms of regulation of activity of S. clearly are found at S.'s change in hematothermal animals. After a degeneration of all nervous elements of a noncardiac origin in S. the endocardiac nervous system remains and functions (see). As endocardiac (peripheral) reflexes there can be reflex influences from one department of S. on another changing force of reduction and other functions of a myocardium. So, the increase in stretching of a myocardium of the right ear arising under natural conditions at increase of inflow of blood to S. against the background of its low initial krovenapolneniye leads to strengthening of reductions of a myocardium of a left ventricle. If
S. is overflowed with blood, then additional stretching of its venous receivers the inflowing blood oppresses sokratitelny activity of a myocardium of a left ventricle owing to what less blood is thrown out an aorta. Thus, endocardiac peripheral reflexes, regulating a krovenapolneniye of arteries on an entrance, represent the mechanism of regulation on «indignation».
Regulation of activity of S. an endocardiac nervous system interacts with extracardiac mechanisms of regulation of arterial pressure (see) also supplements them.
It is known that cordial emission increases especially, than the bigger amount of blood during a diastole inflows to S. on veins. At the same time force of reduction of a myocardium of ventricles increases in proportion to increase in resistance (pressure of blood) in arterial system. Calculations show that at sudden forcing of S. in arterial system not of 60 — 70 ml of blood, as usual at rest, and 150 ml, systolic pressure in it could rise to 400 mm of mercury. However the arterial system is protected from powerful blows of blood, pernicious for an organism, thanks to the regulation which is carried out by an endocardiac nervous system. Overflow of cameras C. the inflowing blood (as well as substantial increase of pressure of blood in the mouth of an aorta and in coronary vessels) by means of endocardiac peripheral reflexes oppresses reductions of a myocardium. The page at the same time throws out in an artery not a half as they is normal, the blood which is contained in ventricles, and smaller quantity. The delay of blood in
cameras C. causes increase in diastolic pressure in his cavities and decrease in a venous inflow. Thus, the excessive volume of blood, to-ry could lead to harmful effects at sudden emission it in an artery, is late in the venous system having big reserve capacity. Danger to an organism is constituted also by the reduction of cordial emission capable to cause critical falling of the ABP. However insufficient filling by blood of cameras of heart and coronary vessels by reflex reactions of an endocardiac nervous system causes strengthening of reductions of a myocardium. At the same time ventricles at the time of a systole throw out not a half, but bigger amount of the blood which is contained in them. Owing to increase at the same time in a gradient of a venous inflow blood begins to inflow strenuously to heart from veins.
The specified patterns were revealed in experiences on the isolated S. with completely switched off noncardiac nervous system. In natural conditions the endocardiac nervous system is not autonomous. It represents only one of links of difficult hierarchy of mechanisms of nervous control of Page.
Noncardiac nervous control of activity of S. is carried out by kernels vagus nerve (see) in a myelencephalon and sympathetic nerves of upper five chest segments of a spinal cord. The impulses arriving to S. on fibers of sympathetic nerves cause increase of serdtsebiyeniye (positive hronotronny action), increase force of reductions (positive inotropic action) and excitability of a myocardium (positive bathmotropic effect), increase the speed of carrying out excitement (positive dromotropic effect). These effects are connected with excitement of beta adrenoceptors of S. (see. Adrenoreaktivnaya system ) noradrenaline allocated by the terminations of sympathetic nerves. Introduction of adrenomimetik to S. causes the same changes of cordial activity, as well as irritation of sympathetic nerves.
Axons of neurons of a back kernel of the vagus nerve located in a myelencephalon reach heart, forming synapses on intraorganic intramural neurons. The strong irritation of the centrifugal heart fibers of a vagus nerve allocating acetylcholine (see) or introduction of the last to S. causes an urezheniye of reductions of heart, weakening of its reductions, reduction of excitability and delay of speed of carrying out excitement in a myocardium (i.e. negative hrono-, other, batmo-and dromotropic effects) owing to excitement of m-holinoretsep-torov of Page. Their weak irritations cause opposite, i.e. positive, hrono-, other, batmo-and dromotropic effects. Such phenomenon is explained by the fact that as a part of intramural efferent neurons, except cholinergic, there are adrenergic neurons having big excitability.
Intramural efferent neurons of S. represent the general final way for the impulses arriving from c. N of page on efferent fibers of a vagus nerve, and the impulses arising in the stretch receptors of an endocardiac nervous system and arriving on endocardiac reflex ways. The nature of konochny influence on S. is defined by interaction of the impulses arriving from these two sources in efferent neurons of an endocardiac nervous system. With the same power of irritation of a vagus nerve the nature of its influence on S. can be opposite depending on a degree of admission of S. and coronary vessels blood, i.e. at most initial irritation of mechanioreceptors of an endocardiac nervous system. Against the background of a considerable krovenapolneniye the irritation of preganglionic fibers of a vagus nerve exerts brake impact on S. Against the background of an insignificant krovenapolneniye of S. (i.e. at weak excitement of stretch receptors of an endocardiac nervous system) there are influences stimulating work of Page. Thereof constancy of a krovenapolneniye of an arterial bed is regulated not only by reflex reactions of an endocardiac nervous system, but also vagus nerves, i.e. duplication of mechanisms of regulation takes place.
I. P. Pavlov showed that among nervous branches of a cardiac plexus there are fibers, the irritation to-rykh selectively leads only to increase of cordial reductions (the so-called accelerating nerve of heart), and nerve fibrils, irritation to-rykh selectively increases force of cordial reductions (the so-called strengthening nerve of heart). The strengthening nerve, according to I. P. Pavlov, plays a trophic role. It exerts impact on carrying out excitement in a myocardium. The irritation is capable to eliminate it blockade of carrying out excitement in an atrioventricular node.
Through kernels of the wandering and sympathetic nerves reflex influences on S. arising at irritation of various reflexogenic zones are implemented. So, pain stimulations of skin cause reflex increase of cordial reductions, irritation of mechanioreceptors of a stomach and a peritoneum — their urezheniye; at strong blow in a stomach there can be a reflex stop S.
Boley a high step of hierarchy of the nerve centers regulating S.'s activity are cent ry ginotalamichesky area (see the Hypothalamus). At artificial electric irritation of various zones of a hypothalamus of reaction of cardiovascular system much more surpass in force and expressiveness of reaction, arising under natural conditions. At local dot irritation of nek-ry points of a hypothalamus it was possible to observe the isolated reactions — change only of S.'s rhythm either only forces of reductions or only extents of relaxation of a myocardium of a left ventricle. Thus in a hypothalamus it was succeeded to reveal the structures capable to regulate separate functions C., but under natural conditions these structures do not work separately. The hypothalamus represents the integrative center, to-ry can change parameters of cordial activity and a condition of cardiovascular system, for ensuring requirements of an organism and all its bodies, at various behavioural reactions arising in response to changes of conditions of external and internal environment.
Representing the highest center of regulation of vegetative functions, the hypothalamus is only the executive mechanism providing reorganization of functions of cardiovascular system and other systems of an organism on the signals arriving from limbic system (see) and cerebral cortex. It is established that the irritation of certain structures of limbic system or new bark along with the corresponding motor reactions can cause simultaneous changes of parameters of cardiovascular system — the ABP, heart rate, etc. The anatomic proximity of points responsible for emergence of motor and cardiovascular reactions is important for optimum vegetative ensuring behavioural reactions of an organism. A cerebral cortex — the body of mental activity providing complete adaptive reactions of an organism not only to current but also to future events. On the mechanism of conditioned reflexes the signals which are directly foretelling approach of these events or a probable possibility of their emergence can cause necessary reorganization of functions C. and all cardiovascular system in that measure in what it is necessary to provide the forthcoming activity of an organism. At very difficult situations, at action of extraordinary irritants there can be disturbances and failures of the highest regulatory mechanisms (neurosises, according to I. P. Pavlov) when along with disorders of behavioural reactions also considerable disturbances of activity of S. and cardiovascular system can appear. These disturbances can be fixed in nek-ry cases on type patol. conditioned reflexes.
Humoral regulation of activity of S. is most carried out by the adrenaline cosecreted by adrenal glands, and other substances circulating in blood. Adrenaline is thrown out blood at emotional and physical pressure; it reacts with p-adrenoceptors of membranes of heart fibers. Excitement of beta adrenoceptors activates enzyme the adenyl cyclase promoting formation of the cyclic AMF necessary for transformation of inactive phosphorylase in active that provides supply of a myocardium with energy. In this way on With. also ions l1 a tion, the interface of excitement and reduction activating phosphorylase and providing influence, creating a positive inotropic effect. Unlike this K+, NSOZ, H+ oppress force of reductions of a myocardium.
Influence S.'s activity and various hormones. Hormone of a pancreas a glucagon renders a positive inotropic effect on S., stimulating adenyl cyclase; hormone of a thyroid gland thyroxine increases heart rate.
Changes of cardiac performance at exercise and emotional stresses. Exercise stresses cause increase in inflow of blood to S. owing to replacement it from veins of extremities the reduced muscles and from veins of an abdominal cavity thanks to build-up of pressure in it (at the expense of a muscle tension of a stomach). This factor works generally at dynamic loads, i.e. at rhythmic activity of muscles. Static loads insignificantly change a venous inflow.
Increase in a venous inflow leads to considerable increase of cordial emission. The important factor supporting the increased cordial emission is considerable vasodilatation of the working muscles and acceleration of a blood-groove that supports a venous inflow to S. on a high level.
At the gross exercise stress the size of a metabolic cost in a myocardium can increase by 120 times in comparison with a condition of rest. In hron. experiments on dogs it is shown that the standard exercise stress (run in the tredbena with a speed of 5 km/h at a bias 5 °) causes the tachycardia remaining during the entire period of loading, increase in systolic pressure and decrease in diastolic pressure in a left ventricle, sharp increase of systolic acceleration of a blood-groove in an aorta, increase in a stroke output and the maximum power of a left ventricle; at the same time also the coronary blood stream considerably amplifies. Such shifts exert the training impact on S., increasing resistance of cardiovascular system to adverse effects, and the physical training becomes an important factor of prevention of defeats of cardiovascular system. Long influence of considerable exercise stresses causes increase in reserve opportunities of heart.
Negative emotions (rage, anger, indignation), causing mobilization of energy resources and emission in blood of adrenaline, lead to increase and strengthening of cordial reductions. These adaptive reactions of S. are useful only on condition of a discharge of sthenic emotions by intensive muscle performance. Control of physical activity during sthenic emotions leads to non-use of the mobilized huge energy potential that can exert adverse impact on Page. Unlike sthenic asthenic emotions (fear, melancholy) cause suppression of energy resources and oppression of activity of S., decrease in blood supply.
Congestive asthenic negative emotions (long condition of fear) make an adverse effect on S.
Physiological aspects of influence of environmental factors on heart
Various environmental factors continuously change the need of an organism for gas exchange and food according to what also activity of Page changes.
Under the influence of a high-rise hypoxia (see) the changes of function C. similar arising at exercise stresses are observed. Changes of function C. in these conditions are directed to decrease in the air hunger of bodies and fabrics appearing at decrease in partial pressure of oxygen in an alveolar air. Compensatory opportunities of S. are not boundless. At big height air hunger of all bodies and fabrics, including and a myocardium, is compensated to the .neena by strengthening of blood circulation. At the same time on an ECG the signs characteristic of acute diffusion ischemia of a myocardium appear. At stronger degrees of air hunger the cordial rhythm urezhatsya and then there comes the asystolia. Periodic influence of a high-rise hypoxia of moderate degree (rises on height of 2000 — 2500 m above sea-level) exerts the positive training impact on Page. Proceeding from it G. I. Kositsky (see t. 15, additional materials) the method of breath through additional dead space of the changing volume offered as means of a training of cardiovascular system for prevention of diseases
of S. K to the environmental factors exerting the expressed impact on S.'s activity sharp temperature variations and noise belong. The processes of thermal control providing maintenance of constant body temperature are carried out considerably with participation of blood circulation. Along with substances and waste products, necessary for life, blood transports and warmly from bodies where it is developed (skeletal muscles, a liver, a brain, etc.), to the vessels of skin and lungs which are carrying out heat output. Temperature increase of the environment, causing vasodilatation of skin and increase in a thermolysis, is followed by increase in minute volume of S. Nagruzk at S. at the same time in addition increases because of increase in viscosity of blood as a result of losses of water at the strengthened sweating; negative impact on S. is exerted also by the arising loss by an organism of salts.
Adverse influence of intensive production or household noise on cardiovascular system is connected with its impact on the psychoemotional sphere. The nervous tension created by noise promotes increase in a vascular tone and the ABP that increases load of S. Besides, at noise there can be neurogenic disturbances of a cordial rhythm.
Negative impact on S.'s activity is exerted by ionizing radiation, strong magnetic fields, electromagnetic waves, an infrasound. Sensitivity of bodies and fabrics to action of ionizing radiation (see) it is proportional to mitotic activity of cells of fabric. From these positions the myocardium can be carried to radio resistant bodies. However, influencing the genetic device, ionizing radiation breaks processes of protein synthesis and causes dystrophy of a myocardium. S.'s reactions to influence of strong variation electromagnetic fields as well as infrasonic waves, have, apparently, the reflex and neuroendocrinal nature. The pathogeny of these reactions is studied insufficiently.
From professional vrednost adverse impact on S.'s activity is exerted by the metalloorganic compounds, carbon sulfur, lead, benzene capable to cause dystrophy of a myocardium and to break a vascular tone.
The PATHOLOGICAL ANATOMY
the earliest structural manifestation of disturbance of metabolism in S. is dystrophy of cardiomyocytes (parenchymatous dystrophy, dystrophy of a myocardium) and stromal elements (mezenkhimny dystrophy).
Dystrophy of a myocardium has various nature; carbohydrate, fatty, proteinaceous (granular) and vacuolar (gidropichesky) dystrophy is most widespread (see. Dystrophy of cells and fabrics ).
Carbohydrate dystrophy of cardiomyocytes is shown generally by reduction or excess accumulation in cytoplasm of a glycogen. The hypoxia is the most frequent reason of reduction of maintenance of a glycogen in cytoplasm of cardiomyocytes (tsvetn. fig. 2). Excess accumulation of a glycogen in cardiomyocytes can be at various diseases, including followed by a hyperglycemia, napr at a diabetes mellitus (see a diabetes mellitus), and also at glycogenoses (see). At light microscopy it comes to light by means of special colourings, and also sometimes emergence of a violet shade of cytoplasm during the coloring by hematoxylin and eosine. The similar basophilia of muscle cells is designated as a basphilic degeneration or as adjournment of «a cordial colloid». An electron - but - microscopically in cytoplasm of cardiomyocytes at the same time extensive fields of a glycogen, and not only like a usual beta form, but also an alpha-form, an also in in the form of the vacuoles filled with a glycogen — glycogenosomes find.
Fatty dystrophy is followed by emergence in cytoplasm of cardiomyocytes of lipids. Depending on the size of lipidic inclusions it can be powdered or small-drop. Are the most frequent reasons of development of fatty dystrophy of a myocardium air hunger, ekzo-and endointoxications. At the diffusion nature of process the myocardium macroscopically looks flabby, dim, clay-yellow color, sometimes with the yellow spottiness (tiger heart) translucent through an endocardium. In some cases fatty dystrophy is shown by formation of the large center in walls of the left ventricle which is macroscopically reminding a fresh myocardial infarction. Emergence of vacuoles of fat in cardiomyocytes can be a consequence of fatty decomposition (lipofaneroz) of membrane structures (fig. 11, a) or hyperlipemias of various genesis (fatty infiltration, fig. 11, b). Electronic microscopically at a lipofaneroza unlike fatty infiltration signs of damage of organellas of cardiomyocytes, first of all mitochondrions and a cytoplasmic reticulum are noted. The outcome of fatty dystrophy of a myocardium depends on its intensity and a damage rate of organellas of cardiomyocytes.
At proteinaceous (granular) dystrophy the myocardium macroscopically looks flabby and dim. Histologically muscle fibers at the same time lose cross striation and in their cytoplasm there are grains of various size which are painted both acid, and main dyes (fig. 12). The essence of this process is not absolutely clear. According to one researchers, based on data of a submicroscopy, it is result of damage of mitochondrions and a cytoplasmic reticulum, according to others, a selective lysis of disks I of sarcomeres of myofibrils therefore the isolated disks A make an impression of grains takes place. Proteinaceous granular dystrophy develops as a result of circulatory disturbances, and also at toxic impacts on a myocardium. At early stages of dystrophy, especially at focal defeat of a cell, process is reversible. It is difficult to estimate functional value of granular dystrophy. Nek-ry researchers consider that proteinaceous dystrophy breaks functions of a myocardium more than fatty.
A version proteinaceous is hyaline and drop dystrophy, at a cut of a glybka of cytoplasm get a form of the drops reminding a hyalin and which are intensively painted acid dyes.
Vacuolar dystrophy is characterized by emergence in cytoplasm of cardiomyocytes of a svetoopticheska of transparent vacuoles. Not only damage of proteinaceous structures of a cell, but also the disturbance of water and electrolytic balance leading to increase in kolloidnoosmotichesky pressure of cytoplasm is the cornerstone of vacuolar dystrophy. The hypostasis of cardiomyocytes (so-called gidropichesky dystrophy) developing at the same time results in dissociation of organellas that considerably reduces function of a cell.
Miotsitolizis — the damage of muscle cells of a myocardium which is characterized at first by easing, and then disappearance at a research in the polarized light of anisotropy of disks A of myofibrils. Process is followed by easing of their tinktorialny properties in this connection at its focal character cardiomyocytes take a form of fabric, as if a corroded moth, and at distribution of process on all cell its cytoplasm in a light microscope looks optically void (tsvetn. fig. 3). Electronic microscopically come to light focal' or widespread lack of myofibrils and the expressed destructive changes of other organellas. Kernels in such cells are, as a rule, kept that gives the grounds to consider this process in most cases reversible. Similar changes often are found at adrenal and toxic damages, and also at metabolic disturbances on the periphery of a zone of a myocardial infarction. Apparently, focal activation of hydrolases is the cornerstone of this process.
The Kontrakturny type of damage of cardiomyocytes consists in destruction of the myofibrillar device of a cell and is characterized by strengthening of anisotropy of disks A. Distinguish several stages of development of this process. Carry those forms of damage to irreversible, to-rye are followed by merge of disks A in a uniform conglomerate. Process can take several sarcomeres or all cell in general. In these muscle fibers at light microscopy cross striation is not defined, and cytoplasm is presented by the dense conglomerate which is painted intensively acid dyes. Electronic microscopic examination allows to establish that this conglomerate is formed by merge of miozinovy threads of disks A. At the same time there is a change of very tectonics of muscle cells to redistribution in cytoplasm of mitochondrions and other organellas.
Identification of precursory symptoms of metabolic damages of cardiomyocytes considerably becomes complicated at S.'s studying in 12 — 24 hours after ascertaining of death since gistofermentno-chemical, electronic and microscopic methods of a research in this case cannot be used any more. Considerable information is given by the methods based on use of the main and acid dyes, in particular fuchsin (see Fuk-sinofiljnaya a degeneration). Studying of a myocardium in luminescent and phase and contrast microscopes, and also in the polarized light is important for identification of dystrophic damages of cardiomyocytes (see. Microscopic methods of a research).
The necrosis of a myocardium develops in the outcome of irreversible stages of dystrophy of cardiomyocytes. Macroscopically necrosis (see) comes to light only during the involvement in process of group of muscle cells or an extensive zone of a myocardium. The site of a necrosis differs in lighter coloring with an icteric shade and a sma-zannost of the drawing of a structure of fabric. Svetooptichesky signs of a necrosis are changes of a kernel with condensation of chromatin in it (karyopyknosis), its disintegration on glybk (karyorrhexis) and in the subsequent — dissolution (karyolysis), and also a denaturation of protein of cytoplasm (a coagulative necrosis) or its excess hydration (a kollikvatsionny necrosis).
Proceeding from the main reasons causing a necrosis of cardiomyocytes it is necessary to distinguish conditionally koronaro-gene necroses (disturbance of a blood-groove in a large artery) and so-called metabolic necroses of a myocardium. The first differ in the size and features of development (see the Myocardial infarction). Critical terms of the ischemia of a myocardium leading to development of a necrosis are important. It is experimentally established that bandaging of a coronary artery for 30 min. leads to formation of micronecroses of a myocardium within the next days. Metabolic necroses of a myocardium (the disseminated micronecroses) usually take several muscle cells or small group of fibers (tsvetn. fig. 4). They are located in all walls of S. with preferential localization in papillary muscles and subendokardi-and flax a layer that testifies to value in their development of the raised functional load. Metabolic necroses of a myocardium are observed preferential at intoxications and a hypoxia of various genesis; quite often they are observed at a thyrotoxicosis (see), a stress (see) and disorders of electrolytic exchange.
The insolvency of a microcirculator bed which is observed at many diseases which are especially complicated by shock (see) happens the frequent reason of dystrophy and necrotic injuries of a myocardium.
Fragmentation of muscle fibers consists in gaps them on separate segments (tsvetn. fig. 5). It can have melkoochagovy character or occupy extensive sites of a myocardium. Most of researchers refer fragmentation of a myocardium to intravital changes, and its diffusion options — by the terminal period. It is not excluded that widespread fragmentation of a myocardium is the cornerstone of inefficient resuscitation; focal fragmentation can have a favorable current. In a zone of fragmentation various forms of dystrophic and necrotic changes of muscle fibers come to light. Kliniko-morfologichesky comparisons allow to assume that one of the reasons of a rupture of muscle fibers is fibrillation of ventricles. Electronic microscopically it is proved that gaps most often are located in the field of inserted disks.
In the outcome of a necrosis of muscle cells the sclerosis develops, to-ry can be macrofocal (postinfarction), melkoochagovy (in the outcome of metabolic necroses of a myocardium) and diffusion (see the Cardiosclerosis).
Mezenkhimny dystrophies of S. are observed most often at general diseases of connecting fabric (see. Collagenic diseases , Rheumatism , acquired ) also have usually the form of mucoid and fibrinoid swelling (see. Fibrinoid transformation ), and also amyloidosis (see).
Fatty dystrophy of a stroma of a myocardium, as a rule, belongs to fatty infiltration and leads to obesity of Page. Increase in amount of fat under an epicardium and in a myocardium is followed by an atrophy of muscle fibers, strength loss of a wall of S. that can lead to its spontaneous gap. The general disturbances of a lipometabolism in an organism, and also decrease in utilization of fat, napr are the reason of obesity of S., at hron. alcoholism.
Inflammatory processes can cover all covers of Page. Depending on preferential localization of an inflammation distinguish endocarditises (see), myocardites (see), pericardis (see) and a pancarditis — defeat of all covers of Page. At the heart of an inflammation can be both nonspecific, and specific inf. process — tuberculosis, syphilis, and also fungal infections, parasitic invasions, etc.
At tuberculosis S.'s defeat meets seldom; as a rule, it is involved in process for the second time. The isolated or combined defeat of an endocardium, a myocardium, a pericardium is observed. The tubercular endocarditis usually has character of warty. It can be result of toxic action of mycobacteria of tuberculosis or products of fabric disintegration, and also a consequence of infection of valves C. with mycobacteria of tuberculosis with development in them specific hillocks. In a myocardium miliary and solitary (focal) forms of tuberculosis are observed (see). Miliary forms of tubercular myocarditis should be differentiated with S.'s sarcoidosis (see the Sarcoidosis). Focal tuberculosis is more often observed in the right auricle or in the thickness of a myocardium of ventricles. Defeat of a pericardium has the nature of miliary tuberculosis more often and is followed by accumulation of serofibrinous or hemorrhagic exudate, the quantity to-rogo can reach 1000 ml and more. At the organization of fibrin the obliteration of a cavity of a pericardium is possible, the numerous nipples presented by fibrin in different phases of its organization or whitish-yellow curdled masses — curdled, or caseous, a pericardis form less often (see).
At syphilis shutters of the valve of an aorta as a result of distribution of inflammatory process from the ascending aorta (mesaortitis) most often are surprised. At the same time in initial phases of process in shutters of the valve the changes inherent to a gumma come to light (see Syphilis), edges quickly is exposed to fibrosis with formation * valve defect of Page. Syphilitic damage of a myocardium can proceed in the form of gummous or hron. productive myocarditis, distinctiveness to-rogo is dominance in infiltrate of plasmocytes, characteristic defeat of small vessels, existence of the gummous curdled centers.
Fungal infections of S. meet seldom. S.'s actinomycosis usually develops upon transition of process from a mediastinum or lungs to a pericardium, and then to a myocardium. There are characteristic abscesses with druses of a fungus in the center (see the Actinomycosis), the cavity of a pericardium is exposed to an obliteration.
One of the most frequent visceral mycoses is candidiasis (see). S.'s defeat is observed usually at generalization of an infection and development of kandidamikozny sepsis.
From parasitic defeats of S. it is generally observed an echinococcus (see). Less often cysticercosis meets (see). and S.'s damages caused by a trichinosis and a balanthidiasis happen extremely rare finds during the opening. At an echinococcal invasion in a myocardium typical echinococcal bubbles develop, to-rye can break in S.'s cavity with dissimination of a scolex and affiliated bubbles on different bodies. Also the break of bubbles in a cavity of a pericardium is possible.
Compensatory and adaptive processes and age changes in S. are expressed by a hypertrophy of muscle cells at the expense of the intracellular hyperplasia of their organellas arising in response to increase in loading (see. Compensatory processes). At decrease in load of a myocardium the atrophy of muscle cells is observed. Processes of an atrophy in S. can take muscle cells of all departments that is followed by reduction of weight of S. — a microcardia. More often this process is observed at senile age and at various is long the current diseases which are followed by exhaustion. The senile atrophy of S. (senile heart) is, as a rule, combined with an atrophy of other bodies and systems of an organism.
Postmortem changes of S. are characterized by a cadaveric spasm of a myocardium, a cut arises much earlier, than in cross-striped muscles, making a false impression of a stop of S. in a phase of a systole. The phenomena close to a cadaveric spasm, apparently, are the cornerstone of the phenomenon of the «heart of stone» developing later a nek-swarm time after an inadequate medicamentous cardioplegia described by cardiosurgeons. Microscopically at the same time find rereduction of myofibrils of cardiomyocytes with development of contractures. Start of «heart of stone» by means of direct massage and an electric impulse is impossible.
Carry an imbibition of an endocardium, valves and an internal cover of vessels to late postmortem changes of S. hemoglobin as a result of cadaveric hemolysis of blood. At the diseases which are followed by intravital hemolysis, this sign appears in earlier terms after death. At a pathoanatomical research the cadaveric gipostaza developing owing to plaint of blood in back walls of ventricles and back departments of an interventricular partition should be differentiated with the developing myocardial infarction.
METHODS of INSPECTION
the Modern clinic has a large number of methods of inspection of patients with damage of heart (see Inspection of the patient). Inspection of the patient includes, in addition to the anamnesis and survey, a physical research of heart, hardware and tool methods, including radiological, and also nek-ry biochemical methods (see Enzymes). Wedge, research C. it is directed to identification structural, or ana-tomo-morphological, changes (by visualization of a structure unavailable to direct observation, S.'s geometry and the vessels adjoining it), and also to detection of functional changes of action of the heart with their quantitative characteristic.
The anamnesis (see) and the analysis of complaints of the patient the features of disease of S. and its manifestation specific to a certain form of pathology of S. allow to establish prescription, e.g., character of stethalgias at stenocardia (see), a myocardial infarction (see), a pericardis (cm), to feature of an asthma (see) with allocation of cardiac asthma (see), existence of disturbances of a rhythm of S. on feeling by the patient of interruptions in S.'s activity; communication of displays of a disease of S. with inf. diseases that can take place at myocarditis (see), an endocarditis (see), with an exercise stress, etc.
Survey of the patient (see) reveals the changes of a constitution and coloring of skin characteristic of nek-ry defects of S., e.g. «a mitral nanism», «a mitral flush» at a mitral stenosis, capillary pulse and «carotid shudder» at aortal insufficiency (see the Heart diseases acquired), «a cordial hump» — protrusion of a thorax in the area C. at its significant increase in connection with inborn defect (see Heart diseases inborn) or acquired in the childhood. During survey such symptoms of heart failure (see) as swelling of cervical and peripheral veins, a Crocq's disease (see), ascites (see), hypostases are found (see Hypostasis).
Physical methods of a research of heart. The palpation (see) areas C. allows to estimate situation and force of an apical beat of S., its change at dilatation and weakening of reductions of S., at an adhesive pericardis (see), sinistroposition and down and strengthening at the expressed hypertrophy of a left ventricle. By means of a palpation specify the existence of a cardiac impulse revealed at survey — concussions of a front chest wall during S.'s systole, caused by a considerable hypertrophy of preferential right ventricle. At patients with an aortal or mitral stenosis the palpation of area of heart sometimes allows to reveal respectively systolic or diastolic trembling. Important information on S.'s activity and its disturbances the palpatorny research of pulse (see) carotid and peripheral arteries gives, the having special value for assessment of a stroke output of S. and diagnosis of aortal defects, and also patol. pulsations (see) in the precardiac area which is observed at aneurism of heart (see) and aneurism of large vessels (see Aneurism, the Aortic aneurysm).
Percussion (see) a thorax is used for establishment of topography and the sizes C. by delimitation of the so-called relative cordial dullness (corresponding to true borders of S.) and borders so-called absolute tupostig only part C. corresponding to that, edges is not covered with lungs. Determine also S.'s diameter and a vascular bundle. By means of percussion specify existence of ascites, the hydrothorax (see) which are observed at heart failure (see).
Auscultation (see) S. and vessels gives rich information on function of a myocardium and the valve device C. The cordial rhythm, quantity listened for a cardial cycle and sonority of cardiac sounds (see) is estimated, a nek-eye to valve defects of S. cordial noise (see) and vascular noise (see), and also a pericardial rub come to light inherent (see the Pericardis). Usually at healthy faces two main cordial tones — a so-called binomial rhythm are listened; seldom at almost healthy subjects splitting of tones comes to light. Splitting, bifurcation of the main tones and emergence of additional tones is observed, as a rule, at patol. processes. Existence of additional III or IV tones causes emergence of a so-called three-membered rhythm, and listening of all four tones of S. is defined as a four-membered rhythm. In patol. conditions emergence still of nek-ry additional tones of various sonority — a polynomial rhythm is possible. Listening of additional tones sometimes is possible only by means of special receptions of auscultation. So, for listening of the deaf patol. the tone creating a cantering rhythm (see Gallop a rhythm), V.P. Obraztsov offered an original method of direct auscultation of S. at dense pressing of an ear of the doctor to a thorax of the patient that creates conditions for the best perception of low-frequency sounds.
Changes of cordial tones at arrhythmias of heart are characteristic (see): disorder of intercyclic intervals (the II tone — the I tone) and the expressed distinctions in the loudness of tones at a takhisistolichesky form of a ciliary arrhythmia (see), «gun» tones at a total atrioventricular block of heart (see), premature emergence and change of loudness of tones at premature ventricular contraction (see).
Auscultation nek-ry patol. tones and cordial noise has pathognomonic or high-specific value for diagnosis of separate defects of S. (e.g., listening of «a rhythm of a quail» at митрально^ a stenosis, «noise of the engine» at a patent ductus arteriosus, etc.), recognitions of a shaggy pericardium (see Heart diseases inborn, the Heart diseases acquired the Pericardis). Sometimes cordial noise happen so-called functional, i.e. not connected with defeat of valves C., a myocardium and a pericardium. Specification of the nature of these noise always demands use of additional methods of a research.
Tool methods of a research of heart. Are among tool methods of a research radiological, ultrasonic, radio isotope, electrophysiologic, etc. The choice of methods in each case is made taking into account their purpose and informational content, depends on a condition of the patient, estimated pathology, character and volume of the data necessary for establishment and specification of the diagnosis. It defines also a combination of the applied methods.
The roentgenoscopy allows to study the sizes, a form and situation C., its pulsation, shift, the rotational movements, to carry out functional respiratory trials (see. Roentgenoscopy ).
The X-ray analysis (see) is made on long focal length (not less than 1,5 m) since with reduction of focal length the sizes of a shadow of Page increase. A clear boundary of S. and vessels receive on short exposure of radiation (0,1 sec.) at a tension on a tube 75 — 85 quarter. For receiving a «rigid» picture increase tension to 115 — 120 quarter. At a X-ray analysis in a direct projection the central bunch of x-ray emission is directed to the V—VI chest vertebrae; the picture is made on a superficial breath. S.'s tomography is applied for the purpose of studying of the left auricle and the main vessels.
Patol. S.'s changes can be found in all body or its separate segments that finds reflection in changes of a configuration of a shadow of Page.
Distinguish three main kinds of a shape of heart: normal (it is described above in the section «Radioanatomy»), mitral and aortal. At a mitral configuration S.'s waist is maleficiated due to increase in the left auricle; the left border is straightened or convex as a result of increase in a left ventricle (fig. 13). Such configuration is observed at mitral defects of Page. The aortal configuration of S. happens at defeats of the valve of an aorta at an idiopathic hypertensia; it is characterized by sharply expressed S.'s waist, the convex arch of a left ventricle expanded with the ascending part of an aorta (fig. 14). At high standing of a dome of a diaphragm and deformation of a thorax S.'s configuration reminds aortal.
Change of the sizes C. — important criterion of its pathology. In size C. radiological distinguish the hypoplastic, drop, normal and increased S.; total increase in S. up to the huge sizes is defined as a cardiomegaly. Hypoplastic S. occurs at persons of the asthenic constitution, high growth, and also at a cachexia. Median vertical position is characteristic of it (a tilt angle apprx. 60 °); the right lower arch in a direct projection is formed by not the right auricle, but a right ventricle; S.'s waist is maleficiated, the arch of a pulmonary artery (fig. 15) acts. So-called drop S. of also small sizes; it is as if suspended on large vessels over a diaphragm and does not adjoin to it. The cardiomegaly is observed at dekompensirovanny defects of S., nek-ry forms of myocarditis, cardiomyopathies.
It is possible to judge extent of increase in S. on the basis of its measurement — a kardiometriya. B. M. Kudish developed rentgenol. schemes of increase in ventricles depending on the prevailing increase in a way of inflow (from the atrioventricular valve to S.'s top) or outflow tracts (from a top to the valve of an aorta or a pulmonary trunk). Increase only in an outflow tract from a ventricle is observed in the presence of an obstacle to outflow of blood (at a stenosis of the mouth or at coarctation of an aorta — for a left ventricle, a stenosis of a pulmonary trunk, pulmonary hypertensia — for a right ventricle). Radiological for a left ventricle it is expressed by lengthening of its top, edges departs down and to the left, rounding of an arch of a left ventricle, and in the left slanting projection — lengthening of all cordial oval. For a right ventricle it is expressed by increase in an arterial cone in the right slanting projection and increase in an arch of a right ventricle in the second slanting projection. Increase in a way of inflow, a cut is observed at mitral and aortal insufficiency, defect of an interatrial partition, etc., radiological it is displayed for a left ventricle by more expressed its expansion, the raised upper bound of a top of S., and in the left slanting projection — increase in a kzada of a contour of a left ventricle, to-ry it is shipped in a diaphragm. For a right ventricle it is expressed by a high position of an atrial and vascular corner, rotundity and its vykhozhdeniye on the right contour, and in the left slanting projection — filling of retrosternal space with an expanded right ventricle.
The detailed analysis of the pulsatorny movements C. and big vessels is of great importance for diagnosis of diseases of S. Distinguish the normal, strengthened, weakened, paradoxical pulsation, and also lack of a pulsation of Page. At the strengthened type of a pulsation the big amplitude of sistolodiastolichesky movements of a left ventricle is defined. Such pulsation is characteristic of an aortal stenosis, an open arterial channel. The weakened type of a pulsation is expressed by the small amplitude of movements of a cordial shadow; it is observed at diseases of a myocardium and a pericardium. Lack of a pulsation of S. on the limited site — a sign of the squeezing pericardis. The paradoxical pulsation of S. is that during reduction there is a protrusion, but not retraction of a contour — the sign characteristic of aneurism of Page.
The important role belongs to a X-ray contrast research C. and vessels — angiocardiography (see). She allows to receive images of various departments of S. and the main vessels, to reveal specific features and anomalies of their structure, patol. changes of ways of a blood-groove.
The method gives the chance to investigate kinematics of heart and pericardiac structures for the purpose of assessment of their function. For this purpose use photographing, serial with short intervals, or high-speed cineangiocardiography, and also record on the videorecorder. The important advantage of this method is the possibility of measurement of the linear sizes, areas, and at a research in two projections — and volumes. Cineangiocardiography final diastolic, final a systolic left ventricle of volumes and their difference (volume of exile) is considered the most reliable. Thanks to high speed of shooting of the image cineangiocardiography is used also for more detailed research of processes of moving of blood of a cavity to a cavity, definition on diameter of a stream of diameter of inter-chamber openings, the extent of defects, the direction and time of pathological dumpings of blood. The combination of this method to a manometriya of cavities of S., edge is carried out through the same catheters, as the injection of contrast liquid, allows to calculate directly rates of volume flow of flows and on the basis of the obtained data — volumes of pathological dumpings. Knowledge of pressure and rate of volume flow of a blood-groove significantly increases informational content of a method, gives the chance to receive except kinematic dynamic and power characteristics of cardiac performance, to calculate the mode of a blood-groove, to-ry will arise after alleged corrective operation. The angiographic research is widely supplemented also with methods of a research by means of cultivation of indicators (colourful, thermal, platinovodorodny) that allows to determine the minute volume of a blood-groove separately on various sites of a blood-groove and to reveal existence patol. shunts. An important element of angiokardiografi-chesky researches is technology of carrying out a catheter to the necessary area of the blood circulatory system. It includes access to the blood circulatory system and further carrying out kateterd from one its department in others. At the same time use as method of catheterization of heart (see), at Krom carry out a catheter to peripheral vessels (elbow, femoral, jugular, subclavial veins, a femoral artery) and further to S.'s cavities, and a puncture — direct introduction of catheters to S.'s cavities on the channel of an aspirating needle. From a cavity catheters carry out to a cavity as on natural circulatory ways, and using a transseptum lny punctures. The angiography is applied also to coronary angiography (see). Visualization of coronary system C. became a powerful clinical diagnostic method of defeats earlier unavailable to a research of vascular area. The angiocardiography demands anesthesiology providing, observance of an asepsis, readiness for resuscitation actions. The method in all its modifications differs in complexity of carrying out a research, high cost of the used equipment and its service, provides high qualification of personnel, is traumatic that limits its use to hl. obr. for a heart surgery and the main vessels.
S.'s visualization is carried out also by means of an echocardiography — a method of obtaining the image of moving S. in a section in real time by means of reception of the echo signals reflected from S.'s structures as a result of impact on them of ultrasonic radiation. The most important positive feature of a method is not - the invasiveness which is ensuring full safety, extremely simplified and reduced the procedure of a research in time. The method allows to estimate a condition and function of the valve device C., an aorta, pulmonary artery, to determine thickness of walls of cameras C. and dynamics of their changes in the course of a cardial cycle, the sizes of cameras C. in a systole and a diastole, and also to calculate the mass of a myocardium, indicators of the central cardiodynamics (final diastolic and final systolic volumes of a left ventricle, its stroke output, fraction of emission) and sokratitelny ability of a myocardium, including one of its most exact tests — the speed of circulator shortening of fibers left zheludoch”. Informational content of a method increases owing to an opportunity synchronously about ekhokardiogram-mine to register an ECG, FKG, the sphygmogram of the central vessels, etc.
The scintillation gamma topography (see Blood circulation, Stsinti-grafiya) gives the chance to establish existence patol. process by means of the image of the radioactive material which is selectively concentrating in these or those areas of body. Depending on properties the indicator can be distributed under the influence of the hydrodynamic reasons in a circulatory bed of S. or is selective collect in fabrics C. owing to inclusion in exchange processes. To visualize a myocardium, intravenously enter 43K or 201T1; in zones of ischemia density of the image weakens. During the use of the indicator 99shkhs only zones of an acute myocardial infarction are visualized. Stsintigrafiya allows not only to outline a silhouette of area of concentration of the indicator, but also reflects its distribution on depth, i.e. eventually supplies with the information on the volumes occupied by the blood healthy and patholologically the changed fabric.
Because of complexity and the high cost of the equipment and its operation, need of operational providing researches with various radioactive drugs, and also especially high a dignity. - a gigabyte. requirements imposed to radio isotope researches the last can be carried out only in well equipped large medical institutions.
The modern cardiology widely uses studying of electric activity of S., with the help a cut estimate dynamics of excitement of S. and reveal its disturbances. The main method of a research of electric activity of S. is the electrocardiography (see) reflecting changes of the electric potentials generated by S. in a body surface. The method allows to reveal and estimate disturbances of automatism, excitability and conductivity of fabrics C. and is applied in medical practice to diagnosis of ischemia and a myocardial infarction (see the Myocardial infarction), cardiac arrhythmias, and also to overseeing by S.'s rhythm at seriously ill patients (see. Monitor observation).
Possibilities of a research of bioelectric activity of S. and its disturbances are expanded by electrocardiotopography — a method of registration of electric field of S. by means of a large number of assignments from the surface of a thorax (electrodes impose on 50 — 400 points). Potential of each assignment is represented on the screen of an oscilloscope by the shining point, brightness a cut is proportional to the level of potential. The intensity of a luminescence of points changing during a cardial cycle is registered by means of high-speed filming. Elektrokar-dttotopogramma represents the set of the shining points reflecting instant distribution of potentials of S. to the surfaces of a thorax. Sometimes the electric car-diotopogrammy is built in the form of the cards representing instant distribution of isopotential lines. The method allows to investigate dynamics of electric field of S. at healthy people and at diseases, facilitates early diagnosis of a hypertrophy of ventricles, provides exact topical diagnosis of focal damages of a myocardium, but is labor-consuming and demands use of the COMPUTER for information processing.
In clinic, except an electrocardiography, the vektorkardio-grafiya is applied (see) — a method of a research of electric activity of S., at Krom information is obtained from two electrocardiographic assignments in the form of the two-coordinate chart. To Vektorkardiogramm interpret as display of a vector of electric activity S. Metod successfully supplements electrocardiographic, increasing the volume of diagnostic data, and at defined patol. states (a hypertrophy of ventricles, disturbances of conductivity, focal damages of a myocardium) has also independent value.
The clinical use is received and intracavitary researches of electric activity of S. Obychno they are conducted along with other invasive researches C. Registration of intracavitary electric potentials of S. is made for the purpose of diagnosis of disturbances of a rhythm and conductivity, most often in options of an elektrogisografiya and researches by means of programmable stimulation of S. Elektrogramma, S. received from cavities of auricles, ventricles and the main vessels, the characteristic distinctions allowing to define the provision of an electrode in S. Eto's cavities have use at S.'s catheterization for control of advance of a catheter on separate cameras C. when rents-genol. control for any reasons is impossible. If the provision of an electrode is known, it is possible to estimate patol. changes of a form elektrogramm for this intracavitary assignment that has diagnostic value. Also synchronous registration of the intracavitary ECG and dynamics of pressure in this cavity of Page can have essential diagnostic information. Such registration happens necessary, e.g., for detection of a dysplasia of shutters of the three-leaved valve at diagnosis of a disease of Ebstein.
Elektrogisografiya (registration of an elektrogramma of a ventriculonector) is made at introduction to S.'s cavities of special catheters with bipolar or polypolar pickup electrodes. Write down potentials of different levels of the carrying-out system of ventricles — a ventriculonector, his legs and Purkinye's fibers. As indications to an elektrogisografiya serve difficult disturbances of a rhythm of Page. It is used for differentiation of ventricular and supraventricular arrhythmias, diagnosis of level of atrioventricular blockade, identification of additional ways of carrying out excitement, etc., and also studying of influence of various pharmaceuticals and operative measures on conductivity. The electrode for an elektrogisografiya is used also for electrostimulation of auricles and ventricles. Contraindications and complications at an elektrogisografiya same, as at catheterization of heart (see).
The intracavitary electrophysiologic research C. by means of programmable stimulation is conducted by introduction to S.'s cavity of two electrodes, one of to-rykh is intended for registration of an intracavitary elektrogramma, another — for drawing a series of the single and double electric impulses able to get to a certain phase of a cardial cycle and to cause extraordinary reduction of Page. Incentives can be given to any period of an atrial or ventricular complex, and everyone subsequent «interval of coupling» of an incentive with some ECG certain element (e.g., a tooth of R or P) constantly decreases, i.e. there is some kind of electric scanning of a cardial cycle. The result of a research gives information on a functional condition of the carrying-out system C., finds out the hidden ways of carrying out, allows to establish the exact topical diagnosis of arrhythmia. The method allows to determine the level of defeat at an atrial zheludochko-vykh blockade, to differentiate supraventricular and ventricular arrhythmias, and also to obtain detailed information on function of the carrying-out system C.
Epicardial mapping of S. is carried out without introduction of electrodes to S.'s cavities and represents record ECG from a surface of the epicardium bared during operation on S. for identification of abnormal ways of premature excitement of ventricles at the patients suffering from attacks of a supraventricular Bouveret's disease. Two electrodes are constantly fixed, third («wandering») consistently move on all surface of the Village. Processing of the obtained data is possible manually, however and bystry their computer analysis is much more exact.
The research of pumping function C. consists in determination of the dynamic or power and kinematic sizes characterizing the act of exile of blood by cameras C. and their filling: pressure in S.'s cavities and the vessels adjoining them, rates of volume flow. the expirations of blood from cameras and in cameras C., and also the sizes characterizing sokratitelny function of a myocardium.
For tonometry in cameras C. and the central vessels (except arterial) there is one reliable way — direct measurement with carrying out in a vessel or S.'s cavity of the catheter filled with normal saline solution, on Krom pressure is transferred to the vneshneraspolozhenny sensor, or the probe with the microsensor of pressure (see the Intracardiac pressure, Sensors, Blood circulation, the Blood pressure, Catheterization of heart). The method has high informational content, but because of complexity of the procedure and injury the hl is applied. obr. in a heart surgery, it is frequent in combination with angiocardiography, and in resuscitation usually as an independent research. In combination with measurement of minute volume of S. the method allows to find hydraulic resistance of various sites of a circulatory bed, the general peripheric resistance in big and small circles, to count a metabolic cost and the spent capacities on advance of blood, to determine sections of valve openings through passage and thus to estimate efficiency of corrective operations. The fluctuations of pressure presented in a graphic form in S.'s cavities in details describe in dynesku a cardial cycle, reflecting the power party and the temporary organization of the phenomena occurring in S. (see. Intracardiac pressure). Pressure in S.'s cavities is the most direct of available to receiving by a source of information on sokratitelny function C. Its good indicators are the maximum size of a mathematical derivative of pressure on time, and also the relation of this size to at the same time developed pressure known as an index of sokratitelny ability of Veragut. Use of a method has the same restrictions, as angiocardiography.
The pro-pool of sivny function C. is the main characteristic rate of volume flow of a blood-groove (see). Its current measurement directly in S. remains a complex challenge, and it is defined indirectly, through other sizes. In most cases use its value average in time — the minute volume of S., i.e. performing cordial emission and heart rate (see Blood circulation) characterizing S.'s productivity as the pump. Minute volume along all its circulatory bed is identical and equal in anatomically normal S. to the minute volume of blood circulation. In the presence of shunts on certain sites it is increased by the size of a volume blood-groove through defect. The minute volume of S. corresponds to the need of an organism for blood supply and only at nek-ry defects of S. and in the conditions of insufficiency of a myocardium it is reduced. Therefore its measurement is important for assessment of weight of heart failure. Measurement in this case is usually performed in the conditions of standard metabolism, and if necessary — in the course of functional loads or pharmakol. tests, e.g. strophanthin about in oh tests (see). Fick's method, and also dilution methods of indicators are among the most reliable methods of measurement of minute volume of S. (see Blood circulation). In the presence patol. dumpings use the same methods, but introduction of indicators and overseeing by their emergence is conducted at the beginning and the end of those sites of circulatory ways, in to-rykh the blood stream is measured.
Widely use the estimated values of minute volume representing the work of heart rate and a stroke output of S. defined reografichesk (see Reografiya). This method of determination of minute volume allows to calculate S.'s productivity for each cycle that is important for assessment of reorganization of work of S. during load and pharmakol. tests, at fast changings of a condition of the patient, etc. Use also more convenient characteristic of intensity of a blood-groove — cardiac index, to-ry represents the relation of minute volume of S. to a body surface. Cardiac index depends on the sizes of a body a little, and its values are more comparable for different individuals, including for adults and children. By data about the minute volume of S. and about average blood pressure in an aorta and a pulmonary artery determine peripheric resistance in big and small circles of blood circulation and the energy spent for overcoming resistance.
In view of big complexity of definition, especially in broad medical practice, the main hemodynamic sizes (pressure, rates of volume flow, the volume of cameras C. and the moved volumes of blood) for the characteristic of work of S. temporary indicators use: duration of a cardial cycle or the return to it size — the heart rate, duration of various phases of a cardial cycle. The heart rate determined by an ECG or pulse is the sensitive indicator of reorganization of delivery function C. since at any change of a stroke output it inevitably shall change to provide an invariance of minute volume of blood circulation. For this reason the cardiac rhythm is the main high-informative monitoring size in systems of intensive observation, and its current values calculated for each cardial cycle — a reliable signal of disturbances of rhythm of cardiac performance (see M onitorny observation).
In need of documentation and the analysis of rhythmic activity of S. for the long periods use a kardiointervalogra-fiya — method of continuous registration on slowly moving paper of duration of cardial cycles in the form of vertical pieces, amplitude to-rykh is proportional to duration of an interval R — R.
Duration of phases of a cardial cycle characterizes the temporary sequence of the events making S.'s activity (see Polikardiografiya); its disturbances are inherent to a number of diseases of S. Dlitelnost of phases of isometric tension and exile of a left ventricle enters in a row the indicators characterizing sokratitelny function C. Extent of the majority of phases can be noninvasively determined at simultaneous registration of an ECG, phonocardiogram (see Fonokardiografiya) and carotid pulse (see Sfigmografiya).
The phonocardiography has important independent value as a method of objective registration of sounds of Page. The main field of its use — noninvasive diagnosis of valve heart diseases.
Mechanical activity of S. is shown by levels of arterial and venous pressure (see. Blood pressure, Sfigmomanometriya), a pulsation of vessels (see Pulse), the precardiac movements of a thorax (see Kinetokardiogra-fiya), the reactive movements of a body (see Ballistokardiografiya), etc. (see Dinamokardiografiya, Pulmokardiografiya).
Important link of a hemodynamics of S. is the venous inflow. Its structure can be investigated on the basis of the transformed curve of pulse of a jugular vein. The curve of a venous inflow has the step form, each recession a cut reflects a certain phase of inflow, and depth of recession corresponds to amount of the blood inflowing to S. for this period. At pathology (a stenosis of the left atrioventricular opening, pulmonary S., defects of interventricular and interatrial partitions, etc.) separate mechanisms of return of blood are broken and deposits of separate phases to the general inflow change. The method allows to characterize reorganization of venous return quantitatively.
S.'s biopsy is carried out for the purpose of intravital studying its pestilence foul. changes (restructuring of cardiomyocytes, a stroma and a microcirculator bed of a myocardium, prevalence and expressiveness of a sclerosis and a hyperelastosis of an endocardium or an epicardium) at various diseases. The transdermal puncture biopsy of S. is made by means of the special needle having the ground branches for capture and trim of a piece of fabric. The Kateterizatsionny (endomyocardial) biopsy of S. is carried out by a special catheter — the biotom having the hoes taking and cutting fabric. The material received by means of a biopsy is subjected morfol. to a research. Both types of a biopsy are carried out under control of an electrocardiographic research. At the time of S.'s puncture and a vykusyvaniye of a piece of a myocardium on an ECG there are single or group extrasystoles, there can be changes of a cordial rhythm. Possible complications of a puncture biopsy — S.'s tamponade, trembling and fibrillation of ventricles, a collapse. At-teterizatsionnoy biopsies are possible injuries of papillary muscles and tendinous chords, and also complications, the general for catheterization of cavities of S.
S.'s Pathology includes malformations, damages, diseases and tumors.
Malformations of heart are quite often combined with anomalies of development of large vessels (see Heart diseases inborn). Nek-ry malformations are shown only by inborn disturbances of conductivity (see the Heart block) or existence of additional conduction paths (see Wolff — Parkinson — Whyte a syndrome).
Distinguish the closed S.'s damages and open (wounds). S.'s wounds divide on chipped and cut and fire. Depending on the nature of wound channel allocate the wounds which are not getting and getting into S.'s cavity; the last subdivide on blind and through.
The closed damages. According to E. A. Wagner (see t. 15, additional materials), the closed S.'s damages make 7,5% of all stupid injuries of a thorax. They result from blow or a prelum its heavy objects, influences of a blast wave, during the falling from height, etc. Depending on the nature of anatomic changes and depth of functional frustration distinguish concussions and S.'s bruises, ruptures of a myocardium (which are getting and not getting into his cavities), damages of endocardiac structures.
The left or right ventricles are most often damaged, other departments of Page are more rare. Disturbance of integrity of coronary arteries, valves, partitions, tendinous chords and papillary muscles considerably makes heavier a condition of patients and worsens the forecast. Quite often along with S.'s damage fractures of edges, damages of easy and other bodies are found that complicates diagnosis.
S.'s damages, insignificant on force, in most cases accurately are not shown and often are left unnoticed without careful inspection. Heavy injuries of a myocardium without disturbance of anatomic integrity of body (bruise) are followed by the expressed symptomatology. General condition of victims heavy. Most of them are uneasy, show complaints to severe pain behind a breast with irradiation in the left hand and a shovel, an asthma, heartbeat, the general weakness. Skin is pale, it is covered cold then, visible mucous membranes of a tsianotichna. A characteristic symptom is tachycardia (140 — 160 reductions in 1 min.) along with considerable arterial hypotension, not korrigiruyemy medicamentous therapy. Perkutor-no practically it is always possible to reveal expansion of borders of S. in the diameter, and auskultativno — dullness of cordial tones. Quite often found thrombosis of coronary arteries leads to development of a myocardial infarction (see) with characteristic changes of an ECG. Ruptures of a myocardium, especially with damage of coronary vessels, cause development of a cardiac tamponade with typical a wedge. manifestations, as well as at open damages.
Diagnosis of the closed S.'s damages is difficult. According to H. N. Malinovsky et al. (1979), only at 7,8% of victims the correct diagnosis was made during 3 days. One of the most important for diagnosis is the electrocardiographic research. On an ECG decrease in amplitude and expansion of a tooth / is observed?, the shift of a segment of ST is lower isolines and inversion of a tooth of T. Along with it short-term or more permanent frustration of a rhythm (premature ventricular contraction, bradycardia, a total or partial atrioventricular block) connected with damage of the carrying-out system C come to light.
Traumatic ruptures of valves, S.'s partitions, chords, papillary muscles are shown intensive patol. noise over area C. However the diagnosis is established seldom during lifetime — most of victims quickly perishes at the phenomena of the accruing heart failure (see).
To lay down. tactics depends on the nature of anatomic damages and weight of cardiac disturbances. At bruises and S.'s concussions carry out conservative treatment. It is directed to elimination of pain, completion of blood loss, improvement of sokratitelny ability of a myocardium, normalization of a rhythm and S.'s conductivity, recovery of a hemodynamics, maintenance of passability of respiratory tracts. Appoint a bed rest to 2 — 3 weeks. All victims in the acute period are given analgetics, cardiac glycosides, steroid hormones, antihistaminic drugs, antiarrhythmic means, carry out an oxygenotherapy. Carefully watch passability of respiratory tracts. Plasma substituting solutions and blood enter only according to strict indications.
Conservative treatment of patients with S.'s concussions, slight and moderately severe injuries in most cases leads to an absolute recovery in 2 — 4 weeks after an injury. At heavy bruises of S., despite use of all complex to lay down. died, the lethality remains high (higher than 60%).
At traumatic ruptures of a myocardium urgent surgery — sewing up of a wound of S. for the purpose of a stop of bleeding and elimination of a tamponade of S. Tekhnik of operation same, as is shown at open damages of S. (see below). Acute thrombosis or considerable damages of the main trunks of coronary arteries with the expressed ischemia of a myocardium also demand performing surgery for the purpose of recovery of blood supply of S. (autovenozny aortocoronary shunting). Urgent selection coronary angiography (see) allows to specify the nature of vascular changes of Page. In case of a rupture of endocardiac structures a reconstructive operative measure with use of artificial circulation is necessary. However to lay down. tactics depends on weight of disturbance of cordial activity in the acute period. At successful use of conservative therapy surgical correction of traumatic defects should be carried out during stabilization of a hemodynamics, before emergence of signs of a cordial decompensation. The most optimum term for intervention is considered 2 — the 4th month from the moment of an injury. In the absence of effect of medicamentous therapy and sharp deterioration in cordial activity urgent reconstructive operation is shown. In the preoperative period use an artificial circulatory support (venoarterialny shunting with oxygenation, an intra-aortal ballonirovaniye).
Open injuries of heart in most cases are followed by injury of lungs and pleurae with development of a hemopneumothorax (see the Hemothorax), come to light wounds of a diaphragm, a liver, a stomach, a spleen, intestines, a spinal cord less often, etc. the Vneplev-ralny isolated wounds meet much less often.
Weight of a condition of wounded can not always be connected with the nature of wound (through, blind); the destiny of the victim generally depends on speed of accumulation of blood in a cavity of a pericardium and total amount of blood loss. At small wound openings in a pericardium blood, partially being curtailed, collects in his cavity, causing a cardiac tamponade (see), from a cut a number of victims perishes before receipt in a surgical hospital. In cases when pericardiac defect is big, blood freely follows from S.'s wound in a pleural cavity of a pla outside, without causing mechanical difficulty of work of S. Osobenno heavy cardiac disturbances arise at damage of coronary arteries, the carrying-out system, valves C., partitions, tendinous chords and papillary muscles.
In typical cases a condition of victims at the time of survey heavy. At many of them the short-term or long loss of consciousness is noted. Victims usually have sensation of fear, concerns, show complaints to sharp weakness, pain in heart, feeling of shortage of air and the complicated breath. Inlet opening is usually localized on a front surface of the left half of a thorax ranging from the II edge to a costal arch between parasternal and average axillary lines. Also other localizations of wounds, including an upper half of a stomach are possible. At the wounded pallor of skin, cold sweat, frequent small pulse, lowered by the ABP are noted. At the continuous expiration of blood from a pericardium in a pleural cavity S.'s tones not of an izkhme-nena or are a little weakened; shortening of a percussion sound over lungs and weakening of breath on the party of defeat is noted. Damage of the valve device or S.'s partitions is followed by emergence intensive patol. the noise listened over area C.
In case of development of a tamponade of S. skin pale gray or cyanotic, breath frequent, superficial, is noted noticeable swelling of cervical veins. Pulse of small filling or is not palpated at all, systolic the ABP is lower than a critical level (70 mm of mercury.), diastolic — is not defined, the central venous pressure sharply increases (to 200 — 300 mm w.g.). S.'s borders are evenly increased in the diameter, tones are weakened or are not listened at all. At an urgent rentgenol. a research the signs characteristic of S.'s tamponade come to light — expansion of its borders, a smoothness of contours, absence or decrease in a pulsation on contours of a cordial shadow. In doubtful cases apply a podmechevpdny pericardiocentesis to specification of the diagnosis.
In some cases an exact idea of localization of injury of a myocardium is given by comparison about a wedge, a picture of electrocardiographic data. On an ECG the changes developing as those at a myocardial infarction are noted: decrease in a voltage of teeth an ECG, shift of a segment of ST up or down from the isoline, smoothing or an inverthis of T. Rezhe's tooth it is possible to see the deep tooth of Q, a crenation and expansion of the QRS complex indicating disturbance of intra ventricular conductivity.
Damages of the carrying-out system, coronary vessels, the valve device and S.'s partitions constitute big danger to the rhythm which was injured in connection with permanent disturbance, food of a myocardium and jumps of an endocardiac hemodynamics. Timely conducted X-ray contrast researches of coronary arteries and S.'s cavities (the selection coronary angiography, ventrikulogra-fpya) allow to specify the nature of damages.
At open damages of S. urgent operation — sewing up of a wound (cardiorrhaphy) is always shown. Success of an operative measure depends on timeliness of arrival of the wounded in to lay down. establishment, speed of performance of a thoracotomy (see) and full preoperative preparation. Serious condition of the victim shall not stop the surgeon.
Preoperative preparation in cases of the established diagnosis is carried out in the shortest possible time: necessary emergency treatment is carried out before introduction to an anesthesia and proceeds in parallel with an operative measure. An indispensable condition is the pericardiocentesis (see the Pericardis) for the purpose of the maximum removal of blood from it. In the presence of a hemopneumothorax before operation it is necessary to drain a pleural cavity with obligatory reinfusion of blood (see Hemotransfusion).
Operation is performed under anesthetic. The most accepted access is the left-side perednebokovy thoracotomy in the IV pl of the V interrebbe-rye (see the Thoracotomy). After opening of a pleural cavity of edge of a wound widely part ranorasshirite-ly. The pericardium is opened with a slit 8 — 10 cm long parallel to a phrenic nerve and on 1 — 1,5 cm of a kpereda from it; quickly delete clots and blood from his cavity. The wound is found on a pulse jet of blood on a front or side surface of S. Krovotecheniye temporarily stop manual pressing of a wound. For audit of a back surface of S. it is carefully raised and brought out of a cavity of a pericardium. On a small wound of S. put noose sutures; at more major defects of a myocardium it is more reasonable to apply P-shaped and blanket seams, taking all thickness of a wall of Page. At the time of sewing up of a wound it is necessary to preserve coronary vessels since their bandaging leads to heavy ischemia of a myocardium. In cases of small wounds of coronary arteries the angiorrhaphy is necessary (see). More considerable damages of the main arterial branches of S. demand autovenozny aortocoronary shunting for the purpose of recovery of a myocardial blood-groove. The pericardium is taken in rare separate seams. Through a puncture in the VII—VIII mezhreberye on the srednepodmyshechny line enter an elastic drainage with a gleam of a large diameter into a pleural cavity. After a raspravleniye of a lung the wound of a chest wall is sewn up layer-by-layer tightly.
In the postoperative period special attention is paid to maintenance of an adequate hemodynamics, gas exchange and prevention inf. complications. All victim appoint analgetics, antibiotics, carry out an oxygenotherapy, fill the volume of the circulating plasma; if necessary enter steroid hormones. Carefully monitor preservation of passability of respiratory tracts, timely deleting a phlegm from a trachea.
The forecast depends on weight of damage and timeliness of assistance.
Patients with the acquired traumatic defects of S. (defects of partitions, insufficiency of the valve device) need reconstructive operations using artificial circulation (see).
Features of fighting damages, stage treatment
the Majority of fighting damages of S. make its wounds, to-rye can be through, tangent and blind, and not getting into cavities S. Naiboley heavy of them through and gutter wounds are getting, at to-rykh most of wounded perish in the battlefield and in pmp.
Wedge, a picture and features of surgical tactics depend on localization and extensiveness of damage of Page. The assumption of S.'s damage shall arise at an arrangement of wounds in a so-called zone, dangerous to S.'s wound — to the left of a breast. A wedge, displays of wound of S. it is possible to divide on local and the general. Treat local: existence of a wound of a thorax in S.'s projection, bleeding from a wound, hypodermic emphysema, pains in the area C. The general manifestations are characterized by serious condition of wounded, to-rye complain of sharp weakness, an asthma, try to accept a sitting position, the unconscious state is sometimes noted; skin is pale, the face is covered cold then, pulse frequent, soft, by the ABP low. Weight of a state is aggravated with traumatic shock (see) and acute bleeding. At S.'s tamponade perkutor-but expansion of its borders is defined; congestive veins on a neck are visible; S.'s tones deaf, the apical beat is not defined. On roentgenograms S.'s shadow is expanded, has the form of a sphere, on an ECG decrease in teeth is noted. At nonperforating wounds of S. which were followed by opening of his cavities, a wedge, a picture same as well as at through wounds of Page.
At S.'s wound the immediate surgery is shown. The purpose of operation — elimination of a tamponade of S. and a stop of bleeding. Valuable diagnostic and to lay down. method before operation is the pericardiocentesis. Wounded with uncomplicated nonperforating wounds of S. (without bleeding and a tamponade) are directed to treatment in specialized military field and evacuation torakoab-dominalny hospital. Experience of the Great Patriotic War showed that splinters more than 1 cm in size are in rare instances encapsulated, in most cases they cause a purulent pericardis (see) etc. suppurations, to-rye develop through 1V2 — 2 month after wound. Therefore such splinters are subject to removal before development of the specified complications. The splinters located in a myocardium and an interventricular partition delete according to vital indications.
The first pre-medical aid includes imposing on a wound of an aseptic bandage, administration of anesthetics. The wounded is urgently evacuated the sparing transport on PMP where give the first medical assistance: enter narcotic and cardiacs, antitetanic serum, anatoxin, correct a bandage, then urgently deliver in MSB.
The qualified surgical help at S.'s wound consists in urgent operation under an endotracheal anesthesia; antishock and antibacterial therapy is carried out.
The specialized surgical help consists in treatment of purulent complications, removal of foreign bodys of a pericardium and a myocardium.
can lead Considerable number of the most various factors (current-siko-chemical, hormonal, electrolytic, toksiko-biological, napr, at burns, nek-ry infections, etc.) to development of dystrophy of a myocardium (see the Myocardial dystrophy). Its amyloidosis concerns to the same group of pathology of a myocardium (see). Special group of diseases of not clear etiology are a cardiomyopathy (see) — a congestive restrictive cardiomyopathy, and also a subaorta of l a ny stenosis (Becker's disease). Inflammatory processes can strike at the same time all S. (see the Pancarditis) or its separate structures (see Myocarditis, the Pericardis, the Endocarditis). The most frequent reason of inflammatory diseases of S. — rheumatism (see). The severe defeats of an endocardium of valves C. caused by effects of their rheumatic inflammation most often lead to formation of the acquired S.'s defects (see the Heart diseases acquired) though sometimes as their reason serve also others patol. processes, e.g. atherosclerosis (see), syphilis (see), a myocardial infarction (see), an injury. If the endocarditis most often has rheumatic character, then myocarditis quite often results also from other pathogenic influences: toxic, virus, microbic, infectious and allergic, parasitic, etc. The viral infection, tuberculosis, syphilis can be the cause of a pericardis along with rheumatism. A peculiar aseptic pericardis develops at a myocardial infarction, and also at Dressler's syndrome (see P ostinfarktny syndrome). Regarding cases inflammatory and allergic defeats of S. are connected with general autoimmune diseases (see. Collagenic diseases, Takayasu syndrome). Crushing dystrophic and inflammatory damages of a myocardium can lead to emergence of the centers of a necrosis with their subsequent organization and an outcome in a cardiosclerosis (see). In nek-ry cases lack of any signs of damage of a myocardium or noncardiac pathology forces to recognize S. which are available for sick disturbance of a rhythm idiopathic, i.e. an independent disease (see Arrhythmias of heart, the Heart block, the Ciliary arrhythmia, the Bouveret's disease, Premature ventricular contraction). Various pathogenic impacts on S. arise quite often at diseases of other bodies. These influences can carry humoral or neurohumoral (e.g., at hypothalamic defeats) character. Germination of tumors of lungs or bodies of a mediastinum in S. is possible: also innidiation in S. of various tumors is sometimes observed. Acute or hron. the overload of a right ventricle at increase in resistance to a blood-groove serves as the reason of development of a pulmonary heart in a small circle of blood circulation (see. Pulmonary heart).
S.'s changes connected with pregnancy and childbirth, sports activities — see below. Surgical treatment of heart diseases — see Aneurism of heart, Arterialization of a myocardium, Arterialny Canal, Valvuloplasty, Heart diseases inborn, the Heart diseases acquired Prosthetics of valves of heart, Stenocardia, the Cardiac tamponade.
S.'s diseases in the International classification of diseases, injuries and causes of death of the IX review are included in the section «Diseases of Bodies of Blood Circulation». Really, in some cases it is difficult to draw a distinction between S.'s diseases and vessels. So, at coronary heart disease (see) its defeats, apparently, develop for the second time in relation to vascular disorders (a spasm, atherosclerosis, thrombosis). The most eurysynusic idiopathic hypertensia also belongs to diseases of bodies of blood circulation (see), at a cut of defeat of S. also have secondary character, and many other diseases, at to-rykh patol. process extends both to S., and to vessels (see. Cardiovascular system).
Mental disorders occur at all diseases of S., including at patients with a myocardial infarction, persons with the acquired and inborn defects of S., and also at the patients who underwent an operation on S. in the postoperative period. At a cardiovascular decompensation often there are asthenic and neurosis-like states. They include frustration of a dream, appetite, depres-sivno-dysthymic frustration of mood, fears, hysteriform and senestopathetically - hypochiondrial manifestations. Occasionally there are acute symptomatic psychoses (see) with the expressed alarming and depressive component. At a part of patients they can have long character (up to 1 — 3 month).
The pathogeny of mental disorders at S.'s defects is studied insufficiently. Major importance is attached to a cerebral hypoxia (see), and at inborn defects of S. — to a factor of a dizontogenez (see Ontogenesis). At patients with the acquired S.'s defects secondary neurotic reactions are observed: depressive, alarming and hypochiondrial, isteronevrotichesky are more rare. At nek-ry patients, especially with epilep-toidny and alarming and hypochondriac traits of character, it is possible patol. development of the identity of depressive and hypochiondrial type.
Mental disturbances at patients with inborn defects of S. are more often observed at defects of blue type. Along with asthenic and neurosis-like states various disturbances of mental development often take place: mental infantility (see), patol. formation of the personality, a delay of intellectual development, is more rare — an oligophrenia (see).
Complications of operations on S. in cases of the expressed cerebral hypoxia, as a rule, are followed long (up to 2 months and more) by asthenic and neurosis-like states. In the next postoperative period developing of short-term acute symptomatic psychoses is possible. Occasionally at patients with rheumatic defects of S. are observed long (up to 2 — 3 months) postoperative psychoses with dominance of depressive and crazy frustration. In some cases, at insufficient efficiency of operation and the accompanying psychoinjuring situations, patients with the acquired S.'s defects have «late depressions» with suicide attempts. The complicated operations for inborn defects of S. can be followed, in addition to tserebroastenichesky and neurosis-like frustration, by temporary or permanent strengthening of psychoorganic disturbances.
The diagnosis is based on close dependence of mental disturbances on changes of a somatic state. The differential diagnosis with schizophrenia (see) is necessary generally in cases of long psychoses at patients with the acquired S.'s defects, and also at long postoperative psychoses. The epileptiform syndrome from patients with defects of S. is demanded by an otgranicheniya from epilepsy (see).
Treatment is directed first of all to a basic disease. Besides, at asthenic and neurosis-like frustration apply tranquilizers (Elenium, Seduxenum), and also neuroleptics of soft action (melleril, sonapaks) and antidepressants (amitriptyline, Theralenum). Acute psychoses stop parenteral administration of neuroleptics (aminazine, Tisercinum). At long psychoses appoint course treatment neuroleptics (a haloperidol, trisedyl) in combination with antidepressants (amitriptyline, Melipraminum). Secondary neurotic reactions and patol. development of the personality is demanded by uses of different types of psychotherapy (see) — rational, suggestive, etc.
Tumours of heart divide Tumours on primary, to the Crimea carry high-quality and malignant new growths, coming from fabrics C. and a pericardium, and secondary — malignant tumors, coming from extracardiac fabrics, but metastasizing in a pericardium and a muscle of Page. Pseudoneoplasms of S. sometimes call the organized intracavitary blood clots having a tumorous configuration and S. similar to tumors a wedge, manifestations.
Primary tumors of heart meet very seldom. On localization distinguish tumors of a pericardium, a myocardium and an endocardium; allocate also intracavitary and intraparietal new growths. On frequency benign tumors of S. prevail, to the Crimea carry a myxoma, and also a rhabdomyoma and gemaigiy S.
Miksoma (see) — the most frequent primary benign tumor of S.; it makes apprx. 50% of all his benign tumors. Usually it develops from an endocardium of auricles and has macroscopically an appearance of the polyps or papillomatous growths on a leg from 1 to 12 cm which are located in left, sometimes in the right auricle.
The wedge, a picture depends on localization, existence and degree of obturation of an atrioventricular opening. At a myxoma of the left auricle it is most typical a wedge, the picture corresponding to manifestations of a mitral stenosis (see the Heart diseases acquired) in combination with dlitelnsh subfebrile condition, anemia, a disproteinemia and quite often repeated arterial embolism elements of a tumor. Among a wedge, manifestations there can be persistent cough with a pneumorrhagia, faints, a fluid lungs. At S.'s auscultation often it is found, as well as at a mitral stenosis, strengthening of the I tone of S., diastolic noise in Botkin's point and accent of the II tone over a pulmonary trunk. Diagnosis is complicated and quite often establish the wrong diagnosis of rheumatic defect of S. which is also often proceeding with subfebrile condition, acceleration - ROE, increase in level alpha and dins-ma-globulins of blood. Despite the high-quality nature of a tumor, its perhaps early recognition in connection with possible development of heavy complications (multiple embolisms, S.'s decompensation) is necessary. Features of diastolic noise (at a myxoma it has no presystolic strengthening more often, being limited proto - and mezodiasto-ly) and in some cases the expressed dynamics of noise and loudness of the I tone at changes of position of a body of the patient help with differential diagnosis with a mitral stenosis. For specification of the diagnosis use contrasting of cavities of S. carbon dioxide gas, radio-isotope photoscanning, a perfused stsintigrafiya of a myocardium, angiocardiography (see), however the most informative and nontraumatic diagnostic method is the echocardiography (see). At a myxoma of the left auricle echocardiographic under a front shutter of the mitral valve the echo signal in the form of «cloud» occupying 3/4 or all diastole is registered. This effect is connected with balloting of a tumor in an atrioventricular opening at S. V reductions the left auricle at the time of a systole the echo signal having a characteristic appearance of «monetary columns» is defined. Sectoral ultrasonic scanning is of great importance for detection of a myxoma of S. (see. Ultrasonic diagnosis).
Treatment operational. Successfully executed operation usually always leads to an absolute recovery.
The rhabdomyoma (see) makes apprx. 20% of benign tumors of S. Makroskopicheski it usually has an appearance of the multiple nodes more often located in a wall of ventricles, is more rare — auricles. S.'s rhabdomyoma occurs, as a rule, at children and can be combined with a tuberous sclerosis (see).
Hemangioma (see) meets at children also more often.
A wedge, manifestations of a rhabdomyoma p S.'s hemangiomas depend on their size and localization. Prp the big sizes of a tumor arrhythmias and heart failure are observed.
The diagnosis of these tumors is extremely difficult. To its establishment apply the same methods, as to identification of myxomas.
Malignant primary tumors of S. are sarcomas and mesothelioma of a pericardium.
Sarcomas can proceed from walls of auricles (more often than right), from a partition of auricles, more rare — from walls and a partition of ventricles. Meet veretenoobraznokletochny sarcoma more often (see), is more rare — giant-cell and kruglokletochny. In nek-ry cases kruglokletochny sarcoma diffuzno infiltrirut all S. and causes significant increase in its sizes. However more often sarcoma has an appearance of the node destroying a myocardium and giving metastasises. Clinically S.'s sarcoma is shown by quickly progressing heart failure (see), conducts edges by the death of the patient. During lifetime this disease is almost not diagnosed.
Mesothelioma (see) develops from a mesothelium of a serous cover, affects both leaves of a pericardium and can grow into a myocardium. Clinically proceeds in the form of an exudative pericardis (see); it is diagnosed by means of a X-ray analysis (see) and S.'s rentgenokimografiya, electro-and an echocardiography, and also a computer tomography (see the Tomography computer) •. Treatment operational.
Secondary tumors of heart meet more often than primary. They are found more than in 5% of the dead from opkol. diseases: at cancer of a lung, at tumoral diseases of the hemopoietic fabric, a breast cancer and a melanoma. Distinguish macronodular and small nodular metastasises in the Village. Large nodes with a diameter from 1 to 5 cm have an appearance of roundish educations with quite clear boundary and are located in different sites C., considerably acting over a surface and changing its configuration, or in the form of polyps, vdajayas in a cavity of Page. Small nodular metastasises with a diameter from 0,1 to 1 cm more often happen are disseminated through a pericardium and an epicardium, is more rare — on a myocardium.
Wedge. manifestations of metastasises of malignant tumors in S. depend on their size and localization and are quite often blocked by symptoms of defeat of other bodies, and also symptoms of the general intoxication. Idiosyncrasy the wedge, pictures of largely nodal metastasises in a myocardium is heart failure, quickly progressing, refractory to treatment, in combination with various disturbances of a cordial rhythm. The large polipoobrazny metastasises which are located in S.'s cavities can cause emergence patol. the noise imitating an auskultativny picture of defect of S. Vazhnymi for diagnosis of distribution of tumoral process on a myocardium there can be changes of an ECG imitating a myocardial infarction and other manifestations of an acute disorder of coronary circulation without the subsequent their positive dynamics. Radiological increase in a cordial shadow, its mnogokonturnost can be found. By means of an echocardiography reveal zones of an akineziya or a hyperkinesia. Small nodular metastasises, without breaking a hemodynamics, in most cases have accurate no wedge, symptoms. At metastatic defeat of a pericardium more often than at other forms of tumoral damage of heart, the exudative pericardis develops (see) with symptoms of heart failure. The most informative the wedge, symptoms of germination of a tumor in a pericardium and a myocardium is a combination of such signs as persistent pain to areas C., a pericardial rub and a syndrome of a prelum of an upper vena cava. Not recognizable timely tumoral pericardis leads to S.'s tamponade with bystry progressing of heart failure and can be a proximate cause of death of the patient.
Recognition of secondary tumoral defeat of a pericardium at onkol. patients is based on symptoms of an acute pericardis (fibrinous, vypotny, konstrik-tivny), quickly accruing increase in a cordial shadow on roentgenograms in combination with reduction of a voltage of ventricular complexes by an ECG, emergence of ekhonegativny space in the field of a back wall of a left ventricle, detection of atipichesky cells at tsitol. a research of the liquid received at a pericardiocentesis. Possibilities of echocardiographic diagnosis of metastasises and germination of a tumor in a pericardium and S.'s muscle are limited. It is possible to reveal only the metastasises located in S.'s cavities or in the field of a back wall of a left ventricle, sometimes in an interventricular partition. Metastasises of a tumor in a pericardium or a myocardium also create ekhonegativny space, but unlike a pericardiac exudate it is observed not throughout, and on the limited site.
Treatment of secondary tumors of S. is carried out against the background of complex therapy of primary tumor. At accumulation in a pericardium of a significant amount of exudate its repeated evacuation or constant drainage of a cavity of a pericardium with introduction of antineoplastic means are shown.
Influence of pregnancy and childbirth on heart
Influence of normal pregnancy (see) on S. it is caused by hl. obr. increase in body weight of the woman, inclusion of additional placental blood circulation and change of function of the endocrine system which is expressed in strengthening of the exchange processes directed to satisfaction of requirements of the growing fruit and removal of products of its exchange. Essential value has change of conditions of a hemodynamics, to-rye at normal pregnancy are rather same. The volume of the circulating blood considerably increases from the II trimester of pregnancy generally at the expense of the volume of the circulating plasma (fi-ziol. hydremia of pregnant women), to-ry accrues since the end of the I trimester and reaches a maximum to 29 — the 32nd week of pregnancy against the background of decrease in a hematocrit (on average for 35%), viscosity of blood and the general peripheric resistance to a blood-groove. Already increase in the I trimester of pregnancy stroke and the minute output of heart (MOH). On 29 — the 32nd week of pregnancy of MOS more than on V3 exceeds the values before pregnancy, and this increase happens together with increase of cardiac index, to-ry in the same terms also increases almost by V3. At the end of the last trimester of pregnancy all specified changes tend to nek-rum to regress, and MOS decreases almost to reference values (approximately only for 10% exceeds MOS values before pregnancy). Noted changes create premises for preferential volume load of Page. Work of a left ventricle of S. increases from the I trimester and reaches a maximum in terms of 29 — 32 weeks of pregnancy, increasing approximately on Vg according to growth of MOS, and then also in proportion to MOS decreases by the end of pregnancy. At polycarpous pregnancy of the loudspeaker of volume of the circulating plasma, MOS and other indicators it is more expressed on extent of changes and corresponds to bigger load of S. that should be considered during the definition of the forecast of pregnancy and childbirth.
Change of the sizes C. at pregnancy corresponds, according to an echocardiography, to dynamics S. volume is nude-gruzki. The sizes of the left auricle gradually increase (on average from 29,7 mm in the diameter at nonpregnant women to 33,1 mm to 33 — the 36th week of pregnancy). End-systolic and diastolic volumes of S. increase approximately on 1/5 — 1/4 from reference values to duration of gestation of 29 — 32 weeks, and by the end of pregnancy their reduction is observed a nek-swarm. Also thickness of a myocardium and its weight increase. However increase in mass of a myocardium has no character of a true hypertrophy since it does not go beyond normal ratios between the body weight and Page.
Changes of an ECG prd pregnancies are naturally shown in gradual shortening of time of atrioventricular, intra pre-serdnoy and intra ventricular conductivity, and also in change of an electrical axis of S. „Due to S.'s acceptance more horizontal position the average size of a corner of an electrical axis by the end of pregnancy decreases on 10 ° and more. In process of increase of durations of gestation the tooth of R raises in assignments of I and aVL and aVF and aVR decreases in assignments of III. Essential increase in a voltage of a tooth of Q is observed in III and to a lesser extent in aVR and the left chest assignments. The tooth of T goes down at most of pregnant women, especially by the end of pregnancy. In the second half of pregnancy it is considerable more often than at nonpregnant women, the negative tooth of T in assignments of III is registered, Vx and V2 and smoothed or two-phase — in assignments of V3 and V4. Approximately at 8% of women in the second half of pregnancy in assignments of V5 and V6 the reduced tooth of T comes to light, amplitude to-rogo does not exceed 0,1 mm.
On the phonocardiogram (FKG) during pregnancy a little more frequent splitting of I and II tones of S. Znachitelno is observed less often III and IV tones come to light, also increase in duration of an interval the II tone — the III tone is noted. S.'s noise in connection with increase in systolic emission, increase in power of cordial reduction and decrease in viscosity of blood come to light more often than at nonpregnant women. Generally they are registered over a pulmonary artery and Botkin's point and have a little big amplitude and duration. According to different data, 7 — 14% of pregnant women have a syndrome of a prelum of the lower vena cava (see Venas cava). Generally it develops after 30 — 32 weeks of pregnancy. Most of women at the beginning of emergence of this syndrome complain of not holdku air. Breath becomes frequent a little, however the expressed asthma meets seldom. Further there are a weakness, dizziness, blackout, a sonitus, pallor of skin. Cold sweat, nausea, vomiting are quite often observed, the loss of consciousness is sometimes noted. Usually a wedge, manifestations of a syndrome of a prelum of the lower vena cava are observed at decrease in the systolic ABP by 25 — 30 mm of mercury. and more and falling it lower than 85 — 80 mm of mercury. Separate cases of decrease in the systolic ABP to 50 — 40 and diastolic — to 30 mm of mercury are registered. Sometimes the ABP falls so that he does not manage to be defined by Korotkov's method (see. Blood pressure). Forward arterial hypotension arises more often and quicker at a hydramnion, polycarpous pregnancy, a large fruit. Studying of the main indicators of a hemodynamics at emergence of a syndrome of a prelum of the lower vena cava showed that almost right after turn of the woman on a back the minute volume of S. decreases by 25 — 30%. However the ABP during this period can change a little owing to reflex increase in peripheric vascular resistance. Heart rate originally usually increases a little. However in 4 — 6 min. the urezheniye of cordial activity is in most cases noted. It causes further decrease in minute volume of S. by 50% and more that involves falloff of the ABP and development of a picture of a collapse (see). Among other changes of a hemodynamics arising at a syndrome of a prelum of the lower vena cava decrease in the central venous pressure, reduction of volume of the circulating blood, delay of speed of a blood-groove, build-up of pressure in veins of the lower extremities and intervillous space of a placenta come to light. At emergence of this syndrome the bradycardia at a fruit reaching 70 — 50 reductions in 1 min. quite often comes to light.
Usually vascular collapse at a syndrome of a prelum of the lower vena cava does not demand any medicinal treatment. First of all it is necessary to turn the woman sideways. However untimely holding this action can threaten life of a fruit and health of the pregnant woman.
Features of a course of pregnancy and the forecast of childbirth at cardiac pathology. For the forecast of pregnancy bigger value, than the nature of defeat of S., have extent of compensation and a functional condition of a myocardium. The known role is played by age of the pregnant woman. Most often the problem of pregnancy against the background of cardiac pathology arises in connection with rheumatic defects of S., to-rye come to light at 1,2 — 4,7% of pregnant women. At women 35 years suffering from S.'s defect are more senior, heart failure (see) is observed approximately twice more often than at younger age. Adversely pregnancy at patients with S.'s defects in the presence of a multiple pregnancy and such associated diseases as hron proceeds. nephrite (see), a thyrotoxicosis (see), and also at anemia (see), obesity (see), accession of acute infections and late toxicosis of pregnant women (see Toxicoses of pregnant women).
Allocate two critical periods, during to-rykh deterioration in compensation of blood circulation and development of heart failure in pregnant women with S.'s diseases is most often observed: the first — in terms approximately from 24th before the 32nd week of pregnancy, the second — at the time of delivery and in the first several days after them. Heart failure can develop also in other durations of gestation since 14 — 16 weeks, however during 24 — 32 weeks it arises most often. Therefore each pregnant woman with a disease of cardiovascular system at the first visit of clinic for women shall be sent to a specialized hospital for a careful kardiol. inspections, including and special revmatol. researches. If the functional condition of the blood circulatory system is recognized as unsatisfactory or active rheumatic process is established, the issue of abortion in terms up to 12 weeks is resolved (after necessary preliminary therapy).
At an aggravation of rheumatic process or emergence of a decompensation of blood circulation after 12 weeks it is necessary to carry out antirheumatic and cardiotonic therapy to terms; in case of lack of effect it is reasonable to interrupt pregnancy in terms up to 20 weeks. During this period there can be a question of surgical treatment of defect of Page.
The second obligatory hospitalization shall be performed at the beginning of the period of the greatest hemodynamic loads of S. (24 — the 32nd week of pregnancy). The patients who are in a condition of compensation and well transferring pregnancy can be written out through lV2-2 of week after inspection and preventive treatment. Pregnant women with unstable compensation of blood circulation shall be in a hospital during all this period. Pregnancy can be interrupted only if active cordial therapy is inefficient and the decompensation progresses. Abortion by small Cesarean section is undesirable as pregnant women with dekompensirovannymp S.'s defects badly transfer operative measures. Surgical correction of defect of S. can be made according to vital indications.
The third obligatory hospitalization shall be performed at duration of gestation of 36 — 37 weeks for training of the woman for childbirth (see). As the decompensation of blood circulation can arise in labor and in the first several days after them, it is necessary to carry out preventive therapy to this period. At patients with very heavy defects of S. it is desirable to carry out delivery in the conditions of hyperbaric oxygenation (see).
At the pregnant women suffering from rheumatic defects of S. critical terms of an exacerbation of rheumatism are noted: to 14 weeks of pregnancy, on 20 — 32nd week p on 5 — the 7th day after the delivery that generally depends on hypofunction of pituitary and adrenal system. On 15 — the 28th and on 38 — the 40th week of pregnancy when the level of corticosteroids in blood increases respectively in 10 and by 20 times in comparison with initial at the beginning of pregnancy (that is explained by excretion of steroid hormones the created placenta and adrenal glands of a mature fruit), on the contrary, is observed improvement of a course of rheumatic process. At patients with rheumatism during pregnancy quite often recurs an inflammation in hron. the centers of an infection (most often in palatine tonsils). Under the influence of infectious and toxic factors at 60% of patients during pregnancy function of a thyroid gland becomes more active. Due to the exacerbation of rheumatism and deterioration in function of a myocardium during pregnancy there can be for the first time disturbances of a rhythm and conductivity of Page. Under the influence of developing fiziol. hypervolemias (increase in volume of a blood plasma by 50 — 60%) in the II trimester of pregnancy signs of a preclinical or initial clinical stage of disturbance of blood circulation at patients with rheumatic defects of S. accrue. At inborn defects of S., especially at septal defects and an open arterial channel, the hypervolemia promotes emergence of dumping of a venous blood into an arterial bed. At inborn defects of S. of blue type (Eyzenmenger's complex, a tetrad and Fallo's pentade, etc.) terrible complication of pregnancy is increase of a hypoxemic syndrome. Hron. the hypoxia, is more often on 3 — the 4th day after the delivery, passes from sub-compensated in dekompensp-rovanny that can lead to a lethal outcome. At patients with inborn defects of S. during pregnancy and especially in a puerperal period tendency to development of a bacterial endokar-yit increases.,
At pregnant women with S.'s defects which are followed by arterial hypertension accession of late toxicosis in early terms (a nephropathy, a preeclampsia) is rather often observed. Spontaneous childbirth at patients with heavy defects of S. under the influence of the hypoxia promoting sokratitelny ability of a uterus proceeds much quicker than usual. In the third period the raised blood loss (apprx. 350 — 400 ml of blood) explaining * sya with developments of stagnation in a small basin is, as a rule, observed. At the newborns who were born at mothers with heavy rheumatic or inborn defects of S. a hypotrophy (see), prematurity, functional immaturity with the phenomena of a pneumopathy are quite often observed (see). At such women children in asphyxia and with anomalies of development are born more often.
Most failures of pregnancy and childbirth are observed at emergence and development of pregnancy against the background of an active phase of rheumatic process, a bacterial endocarditis, defects of S. which are followed by heavy pulmonary hypertensia, atrio-and a cardiomegaly, load of a left ventricle (aortal insufficiency, etc.), inborn defects of blue type (a complex and Eyzenmenger's syndrome, etc.), and also died tsa those l ny and r itm and and.
Admissibility of pregnancy at S.'s diseases is defined by assessment of risk of emergence of complications. L. V. Vanina (1971) suggested to allocate risk degrees of emergence of complications at the pregnant women having S. Razlichayut's diseases four risk degrees:
The I risk degree if pregnancy develops at patients with S.'s defect without the expressed symptoms of heart failure and an aggravation of rheumatic process;
The II risk degree if pregnancy proceeds at patients with S.'s defect which is followed by initial symptoms of heart failure (short wind, tachycardia) in the presence of symptoms of rheumatism of the I degree of activity;
The III risk degree is established at a combination of pregnancy to dekom-pensirovanny defect of S. to signs of dominance of right ventricular insufficiency, at rheumatism of the II degree of activity, pulmonary hypertensia, emergence of a ciliary arrhythmia; The IV risk degree is available for the patients suffering from dokompensirovanny defect of S. with signs of left ventricular or total failure in the presence of an active phase of rheumatism atrio-or cardiomegalies, is long the existing ciliary arrhythmia with thromboembolic manifestations, heavy pulmonary hypertensia. Pregnancy is considered admissible at I and II risk degrees, and at III and IV — is contraindicated.
The outcome at pregnancy at patients with diseases of cardiovascular system improves on condition of stay in specialized kardiol. establishment where are used sovr. diagnostic methods, including cytologic and immunofluorescent ways of a research of breast milk (colostrum) on a degree of activity of rheumatic process, studying of a condition of functions C., determination of parameters of external respiration, etc. is carried out. Preliminary establishment of tolerance to an exercise stress (a veloergomet-riya and a research of the central hemodynamics) is important.
Pregnancy and childbirth in some cases become admissible after surgical correction of defect of S., napr, after the mitral commissurotomy executed to or during pregnancy. At delivery of women with S.'s disease it is necessary to adhere to strictly developed obstetric tactics in relation to women in labor with various forms of cardial pathology.
At inborn defects of S. of blue type childbirth carry out in the conditions of hyperbaric oxygenation that often allows to achieve their happy end both for mother, and for a fruit.
PATHOLOGY of HEART AT CHILDREN
At children all diseases of S. known occur at adults, but structure of incidence at them other. With a bigger frequency, e.g., inborn defects of S. come to light and casuistic pathology, so frequent at adults, as a myocardial infarction is seldom observed. Besides, unlike adults, in structure of pathology of S. at children the age functional disturbances connected with disharmony of development of cardiovascular system and systems of its regulation take place. Such disturbances result from a temporary arrest of development when the structure of a myocardium keeps the properties inherent in the previous age step of development. The asynchronism quite often concerns evolution of the neuromuscular device and is caused by the fact that development of a nervous system of S. generally comes to an end already in 7 — a 10-letnem'vozrasta, and growth of muscular tissue C. becomes the most intensive at children at the age of 12 — 14 years and continues up to 18 — 20 years. This circumstance as well as possible emergence (e.g., in the pubertal period) discrepancies between the volume of a vascular bed and S., together with features of neuroendocrinal reorganization of an organism contribute to dysfunction of the blood circulatory system. Temporary disturbances of activity of the device of blood circulation at children are shown differently. Frustration of a rhythm of cordial activity, arterial hypertension or hypotension are most often observed. To auskul-, to tativny signs of features of cordial activity at children refer so-called functional noise, to-rye are listened at many almost healthy children of different age, since chest. In process of growth of the child the frequency of their identification increases. The reasons causing emergence of such noise are various: the disturbance of nervous control of activity of S. leading to change of a tone of a myocardium, and in particular papillary muscles, acceleration of a blood-groove in mouths of an aorta and a pulmonary trunk (the strengthened adrenergic influences), easy disturbances of biopower processes in a myocardium because of intoxication, an infection. Functional frustration of cardiovascular system at children are, as a rule, passing and do not exert noticeable impact on harmonious development of an organism.
The main organic pathology of S. at children, except inborn defects of S. and large vessels (see Heart diseases inborn), is connected with inflammatory processes in it, rheumatism (a rheumatic carditis), the acquired S.'s defects, bacterial endocarditises (see), nonspecific are most often observed (bacterial, virus, allergic, infectious and allergic) myocardites (see), meet different types of a cardiomyopathy (see) less often, including a subaortic stenosis, a fibroelastosis of an endocardium (see the Fibroelastosis subendokardialjny), tumors of Page. Dominance of an exudative component of an inflammation with more extensive, than at adults, mucoid and fibrinoid changes is characteristic of children's age at a rheumatic carditis (see Rheumatism). It influences weight of a state and is reflected on a wedge, symptomatology. Involvement in patol is characteristic. process of several covers of S. with dominance of inflammatory changes in a myocardium or an endocardium. The symptomatology of diseases of S. at children is similar that at adults, however complaints meet less often. Damage of a myocardium at children is recovered quicker and more stoutly, than at adults. Sclerous changes in a myocardium are less often noted.
INFLUENCE of SPORTS ACTIVITIES ON HEART
Regular physical exercises have significant effect on structure, function, exchange and regulation of activity of Page. They considerably expand its adaptation opportunities and a functional reserve, allowing it is easy to transfer various exercise stresses.
At sports activities so-called sports heart gradually forms. Long hyperfunction of S. leads to its increase for the account fiziol. dilatation of cavities and a hypertrophy of a myocardium, the cut is the cornerstone activation of the genetic device of cardiomyocytes (see. Compensatory processes, compensatory hypertrophy of heart). Unlike patol. S.'s hypertrophies, at athletes it is characterized by preservation of normal proportions of number of fibers and kernels, surfaces and the mass of a muscle cell, and also increase in intracellular ultrastructures and numbers of capillaries per unit mass of a myocardium, increase in reserves of potassium, concentration of a myoglobin, power of system of oxidizing resynthesis of ATP, activation of fermental systems, normal concentration of catecholamines, increase in transport of oxygen to mitochondrions, increase in force and speed of reduction y relaxations of muscle fibers, strengthening of a connective tissue framework, increase in number of nervous elements C.
S.'s weight of athletes makes in most cases 300 — 450 and and, as a rule, does not exceed 500 g, i.e. so-called critical weight; S.'s volume most often within 750 — 1150 ml (11 — 15 ml on 1 kg of body weight) at men and 600 — 900 ml (9 — 14 ml on 1 kg of body weight) are at women. Approximately at a half of the qualified athletes (hl. obr. training on endurance and force) the hypertrophy of a back wall of a left ventricle and interventricular pery is foundrodka. In most cases the mass of a myocardium of a left ventricle reaches 240 g, and the volume of a cavity of a left ventricle — 140 — 230 ml, certain athletes have 290 ml. Thus, S.'s increase at athletes happens generally at the expense of dilatation and to a lesser extent at the expense of a hypertrophy, a cut both the left and right departments of S. U of the female sportswomen training with the large volume of work are exposed, degree of a hypertrophy almost does not differ from that at male athletes. The hypertrophy of a myocardium forms already at the first stages of a physical training then the individual optimal variant of adaptation supported (in the absence of the burdening factors) for many years of a training is formed. The volume of cavities is more dynamic; it changes depending on the level of loadings and a condition of fitness. Increase in diastolic capacity of S. along with increase in a venous inflow and increase in sokratitelny ability of a myocardium allows to mobilize the reserve volume of blood for increase in systolic emission during the performance of loading that considerably increases functionality of S. Sochetaniye of different degrees of a hypertrophy and dilatation reflects different ways of adaptation of S. that depends on a number of factors, including on an orientation of training process, the mode of a training, specific features of an organism of athletes, rates of building of loadings, etc.
The greatest increase in S. is observed at the athletes training on endurance; so, e.g., at marathoners it is expressed more, than at gymnasts. Limits of rational increase in S. shall be defined with sports specialization. So, if, according to an echocardiography, at the athletes training on endurance, the mass of a myocardium of a left ventricle more than 190 g, its final diastolic volume more than 200 ml, thickness of a myocardium more than 14 mm, then it is necessary to conduct additional examination of the athlete; at engaged in sports and combat sport additional inspection it is shown if these sizes make respectively 200 g, 220 ml and 18 mm. At the athletes doing slozhnokoordinatsionny sports, the given indicators differ from the standard norm a little.
In a condition of muscular rest and at moderate loadings the trained S. functions in comparison with unexercised more economically that at rest is shown by an urezheniye of cordial reductions (to 60 — 40 in 1 min.), lengthening of a diastole, the period of tension (generally at the expense of a postsphygmic period and a mechanical systole), shortening of initial velocity of rise in chamber pressure and the period of exile (a so-called phase syndrome of an adjustable hypodynamia of a myocardium according to V. J1. Karp-manu), what reflects the smaller power cost of each cordial reduction. Speed of a blood-groove is slowed down, the ABP tends to decrease, the power of cordial reductions high. The systolic volume of blood is increased, and minute does not differ from that at the persons nezani-toiling with sport. Features haemo - and cardioloudspeakers of the trained S. in a condition of muscular rest are caused not only decrease at rest of activity of sympathoadrenal system and increase in a tone of a parasympathetic part of century of N of page, but also deep reorganization of activity of an organism at the central, system, organ, molecular and ionic levels.
At moderate loadings the satisfaction of an oxygen request occurs at a smaller tension of blood circulation and breath (1 g of a cardiac muscle generates 25 — 30% less external work, than at the same loading of S. of the unexercised person). At maximum loads thanks to more perfect regulation and self-control and a big functional reserve the trained S. is capable to develop the energy unavailable unexercised, as causes high sports results. Heart rate at the same time can reach 200 — 230 blows in 1 min., the ABP — 200 — 230 mm of mercury., systolic volume increases to 150 ml and more, minute — to 30 — 40 l, the maximum oxygen absorption in 1 min. — to 5 — 5,5 l against 200 — 300 ml at rest. As a result of improvement of exchange in a myocardium at loading utilization from blood free fat to - t, a lactate and a glycogen increases. Due to oxidation milk to - you are released about 2/3 necessary S. of energy that reduces local acidosis, reducing fatigue of a myocardium.
S.'s work at big loadings at the trained athletes thanks to improvement of mechanisms of boundaries - and intrasystem regulation is facilitated at the expense of noncardiac factors — effective redistribution of blood, expansion of a vascular bed of the working muscles, development of collateral circulation, decrease in peripheric resistance, increase in assimilation by fabrics of oxygen, etc. The nature of reaction, size of shifts, their interrelation and speed of recovery are caused харак^ by a shooting gallery and size of loading, on the one hand, and the level of readiness of an organism — with another. Even taking into account considerable strengthening of blood circulation at loading and in blizhayshvkhm the recovery period at the trained athletes the general reduction of daily loading is provided.
A certain parallelism between the sizes C. and profitability, and also the maximum aerobic productivity of the blood circulatory system is established that is shown most clearly at the moderate combined hypertrophy and dilatation of Page. Considerable degree of a hypertrophy (wall thickness of a left ventricle more than 14 mm) and dilatation (S.'s volume more than 1150 — 1200 ml or 17 — 18 ml on 1 kg of body weight and the volume of a cavity of a left ventricle more than 220 ml) should be regarded as less favorable option of adaptation connected with excessive mobilization of reserves. Functionally less favourably for athletes and so-called small heart (volume to 650 ml or 9 — 10 ml on 1 kg of body weight and a thin muscular wall — to 10 mm).
At the trained athletes in a condition of muscular rest of an ECG it is characterized by sinus bradycardia, specific elongation of a diastole that is most expressed at the athletes training on endurance. Amplitude of teeth P is quite often reduced, and teeth of the QRS and T complex in standard and chest (especially left) assignments usually much more, than at the persons who are not playing sports. A tooth of T in the III standard, assignments of A VR and F, in most cases negative. Young athletes option of norm can have also negative teeth of T in assignment of U2. Diagnosis of a hypertrophy of a myocardium at athletes according to an ECG is insufficiently reliable that it is confirmed by comparison of data of an ECG and echocardiography. It is caused by the increased functional activity of S. influencing a voltage of an ECG and diffusion character of a hypertrophy (all muscle bulk of S.) that levels expressiveness of the increased action potentials of any part of a myocardium in their integral display to an ECG. Rather often the deformation of the QRS complex characteristic of incomplete blockade of the right leg of a ventriculonector (but without increase in duration of a complex) reflecting most often delay of excitement of the right supraventricular comb and fiziol occurs at athletes. option of development of conduction paths. Similar changes can be also manifestation of a hypertrophy of a right ventricle, true delay of conductivity on the right leg of a ventriculonector.
The segment of ST (it is preferential in chest assignments) is often displaced up for the account fiziol. asynchronism of the early period of repolarization. Vektorkardiogramma is characterized by increase in the area of a loop of QRS and axes of loops of QRS and T.
During an exercise stress considerable changes of an ECG are observed. Already in the period of a vrabaty-vaniye the cardial cycle, intervals of PQ and QT is quickly shortened, segments of PQ and S T can be displaced slightly below than the isoline, amplitude of teeth P and the QRS complex increases; the tooth of T after initial (on the first seconds of work) flattening gradually increases. At loadings of moderate power the shifts which came in the course of a vrabaty-vaniye are stabilized, and at big, especially limit, loadings are gradually aggravated, reflecting the increasing exhaustion (there is a further increase of cordial reductions, decrease in segments of PQ and S T, specific elongation of a systole, decrease in a tooth of L At insufficient fitness and inadequate loadings, besides, there can occur the expressed decrease in amplitude of teeth/?, flattening or inversion of teeth of T, lengthening of atrioventricular conductivity, premature ventricular contraction. During recovery all indicators of an ECG gradually are returned to initial. At more trained athletes the vraba-tyvaniye comes quicker, the phase of stabilization is clearer, decrease in a tooth of T and change of other ECG components are less expressed, recovery occurs quicker.
On the phonocardiogram at athletes duration of I and II tones of S. is rather more, than at unexercised persons, amplitude of of tone over a top S. is reduced, muting of tones and functional noise quite often is found that is caused by physiological eketrakardialny and hemodynamic factors.
At an irrational training the acute and chronic overstrain of Page is observed. The acute overstrain arises suddenly, usually at persons. insufficiently prepared for sharp increase of loading. It occurs at the trained athletes extremely seldom — at a training against the background of diseases or in the burdened conditions (hot climate, highlands, etc.). The wedge, picture corresponds to acute heart or vascular failure. there can be disturbances of coronary circulation with hemorrhage in a myocardium or nekoronarogenny focal and diffusion damages of a myocardium, disturbance of a rhythm of Page. Death is not excluded. The immediate termination of trainings, resuming of sports activities not earlier than in 3 — 6 months is necessary. At the same time the possibility of performance of high loadings is problematic further.
Hron. S.'s overstrain can arise also at the trained athlete against the background of long inadequate loadings, diseases, disturbances, existence of the centers hron. infections, at a training in the changed conditions of the environment without sufficient preliminary adaptation. At the same time dystrophy of a myocardium as a result of hyperfunction (nekoronarogenny character) develops, edges it is shown only by changes of an ECG, usually in the form of a depression of a segment S T, flattening or inversion of a tooth of T, as a rule, without emergence of any symptoms of heart failure and with possible long preservation of high performance in the beginning. In some cases at the same time it is possible to reveal separate disturbances of sokratitelny ability of a myocardium, a hemodynamics, adaptation to exercise stresses. Dynamic electrocardiographic researches, definition of working capacity, potassium and load tests are very important for diagnosis. A crucial role in the mechanism of development hron. S.'s overstrain play metabolic changes — disturbance of ionic balance in a myocardium and the increased maintenance of catecholamines. Terms of the termination of a training or change of its mode are caused by degree of an overstrain, a condition of the athlete, sport, etc. Treatment is appointed individually taking into account a wedge, pictures, medical pedagogicheskikh observations, by the ECG loudspeakers, results pharmakol. and load tests. Rationalization of the motive mode, the psychoemotional status, sanitation of the centers hron is obligatory at the same time, infections, Appoint anti-dystrophic drugs — orotat potassium, inosine, inosine, etc., and also antagonists of calcium (nefedenin, etc.)
After normalization of an ECG the athlete can resume trainings in full under constant observation of the doctor.
Features of anesthesia at cardiac operations and special invasive methods of a research
(From additional materials)
Carrying out the general anesthesia at patients with pathology of cardiovascular system is accompanied by need of maintenance of adequate blood circulation during an operative measure taking into account the nature of a disease. At the same time smaller degree of anesthesia and muscle relaxation, as a rule, is required. In cases with initially low cordial emission light surface anesthesia with use is necessary for ventilation of the lungs of respiratory mix with a large amount of oxygen. Use of electrothermic coagulation for a hemostasis at operations on S. excludes use of all explosive anesthetics (ether, cyclopropane). The tendency to broader use in cardioanesthesiology of an intravenous anesthesia is noted. The gkhremedikation has essential value (see the Anaesthesia). Most often for the purpose of direct medicamentous preparation apply Seduxenum (diazepam), Droperidolum in combination with fentanyl, Promedolum or morphine, to-rye enter intramusculary in 40 — 45 min. prior to operation. To children often enter intramusculary Ketaminum (Ketalorum)
of 5 — 6 mg/kg in combination with Seduxenum. Atropine is applied at bradycardia.
In the period of an introduction anesthesia all manipulations shall be carried out accurately and quickly since patients with pathology of heart are very sensitive even to the short-term periods of a hypoxia or a hypercapnia. The venipuncture and catheterization of veins (see Catheterization of veins puncture) should be carried out, applying local anesthesia novocaine or lidocaine; the intubation of a trachea (see the Intubation) shall be carried out at most shortened period of an apnoea (see Breath). Pharmaceuticals enter slowly that the beginning of an anesthesia was smooth, without sharp hemodynamic shifts. Open
heart operations in the conditions of a hypothermia (see the Hypothermia artificial) are performed under anesthetic at the general cooling of all body (to 30 °) or only the heads of the patient (to 26 — 28 ° in naruzhnokhm acoustical pass). At children cardiac interventions quite often carry out at the deep hypothermia (18 — 20 °) reached by cooling during short artificial circulation with the subsequent its shutdown for the period of operation (up to 50 min.).
Technique anesteziol. ensuring operations on heart in the conditions of artificial circulation (see) it is developed rather fully. At arrival of the patient to the operating room provide keeping track of by the main fiziol. parameters. Measure the ABP (by an indirect method in the beginning), register an ECG in three standard leads. Under local anesthesia make a venipuncture, a venosektion or catheterization of one of peripheral veins and carry out an introduction anesthesia. After that make an intubation of a trachea. Into a stomach enter a stylet, into a nasopharynx and a rectum — sensors for registration of temperature; catheterize a bladder the constant catheter connected to the graduated capacity for control of a diuresis during the entire period of operation. Into a beam artery by its puncture (or by means of an arteriotomy) enter a catheter for constant direct registration of the ABP, and into one of the central veins (outside or internal jugular, is more rare femoral or subclavial) — for registration of the central venous pressure. Then define in blood an initial hemoglobin content, potassium, sodium, calcium, fibrinogen, indicators of a hematocrit, gas exchange, an acid-base state. Provide constant registration of the electroencephalogram. Artificial ventilation of the lungs (see. An artificial respiration) carry out in the mode of a moderate hyperventilation. At separate stages of operation (a sternotomy, deaerating from cardial cavities, suture on an auricle) carry out manual artificial ventilation of the lungs (WILLOWS of L), coordinating a rhythm and depth of breath with manipulations of the surgeon. For an anesthesia, as a rule, use the gas mixture consisting of nitrous oxide with oxygen in the ratio 2:1. The analgesia is supported by fractional introduction of analgetics (fentanyl, morphine). At the systolic ABP it is not lower than 90 mm of mercury. and stability of other hemodynamic indicators can use Ftorotanum. Prior to the beginning of artificial circulation intravenously kanelno enter antibiotics, and before connection of the cardiopulmonary bypass — heparin and in 5 min. make control definition of a blood clotting time. Before artificial circulation in the device administer in addition sedative drugs (Seduxenum), analgetics (fentanyl, morphine) and a muscle relaxant (tubarin or pavulon). After the beginning of the general perfusion of WILLOWS of JI stop, filling lungs with respiratory mix so that they were in slightly inflated state under pressure from - 5 to +10 cm w.g. During perfusion anesthesia is supported by fractional introduction of Seduxenum and fentanyl, or Ftorotanum. Thus systolic shall be the ABP within 60 — 80 mm of mercury., venous pressure — at the level of 5 — 10 mm of mercury. At the ABP higher than 80 mm of mercury. try to obtain its decrease by fractional introduction of vasodilators. The diuresis during perfusion shall make 1 ml! kg at 1 o'clock. Blood gases, hemoglobin, a hematocrit, content of potassium and calcium, and also a blood clotting time control at least every 30 min. After shutdown of the cardiopulmonary bypass recover the adequate volume of the circulating blood and make neutralization of heparin in blood introduction p rotamin-sou of a lfat. During this period apply inhibitors of proteases to normalization of coagulability of blood (Trasylolum. Contrykal, a gordoka), glucocorticoids (Prednisonum, Prednisolonum, Urbazonum, etc.), aminocaproic to - that. the trombotsitny weight, fresh donor blood, and if necessary — fibrinogen. It is very important to provide a sufficient diuresis during this period. The adequate volume of the circulating blood is recovered, being guided by indicators of the central venous pressure, the ABP, pulse and pressure in the left auricle. After the end of operation of the patient transfer to intensive care unit where carry out I V of L and continue careful the monitor of Nov observation (see). At stabilization of a hemodynamics, a complete recovery of consciousness, normalization of temperature and independent adequate breath of the patient transfer to spontaneous breath with supply of the moistened oxygen through an endotracheal tube, and after extubation — through a mask or nasal catheters.
About from an obennost anest e-
z and are also defined by distinctions in a pathophysiology of hemodynamic disturbances at different forms of pathology.
At inborn heart diseases (see Heart diseases inborn) one of the most frequent and characteristic changes is increase or reduction of a pulmonary blood-groove, degree to-rogo depends on expressiveness of dumping of blood from right to left (that is followed by cyanosis) or from left to right. At defects with the reduced pulmonary blood-groove and cyanosis (Fallo's tetrad, a tricuspid and pulmonary atresia) take into account that reduction of a pulmonary blood-groove is normal and increase in blood pressure in a pulmonary artery happens at build-up of pressure in pneumatic ways, low tension of oxygen in an arterial blood and decrease in pH. Therefore during the carrying out WILLOWS of L at patients with the grown poor pulmonary blood-groove avoid essential increase in lungs of pressure on a breath since it can lower even more a pulmonary blood stream and increase, napr, at Fallo's tetrad, shunting of a venous blood. The lowered pulmonary blood stream extends time of approach of effect of effect of inhalation anesthetics. At the same time the drugs administered intravenously reach quicker a brain since practically bypass pulmonary circulation. At patients with the increased pulmonary blood-groove more bystry diffusion of oxygen and inhalation anesthetics in lungs is observed. During operations for inborn heart diseases often there are different arrhythmias connected with anomalies of the carrying-out system of heart and a possible surgical injury of abnormally located conduction paths that demands use of an artificial pacemaker of heart (see the Pacemaker).
Patients with the acquired heart diseases in the preoperative period usually receive cardiac glycosides and diuretics, to-rye can promote development of a hypopotassemia that very reflects adversely on a current of the general anesthesia and operation. Therefore use of these drugs is usually stopped in 36 hours prior to operation. Exceptions when cardiac glycosides are necessary for regulation of cordial reductions are allowed. Before operation reduce doses of anticoagulants. Selection of anesthesiology and therapeutic means shall provide stability of a hemodynamics taking into account hemodynamic frustration at specific heart disease (see the Heart diseases acquired).
At a mitral stenosis it is necessary to avoid use for anesthesia of the means causing tachycardia, naira, Ketaminum. Apply cardiac glycosides, small doses of propranolol to an urezheniye of pulse. Nitrous oxide at a number of patients with a pulmonary hypervolemia can render noticeable toxic effect therefore already at the first signs of hemodynamic disturbances it is necessary to stop supply of nitrous oxide in respiratory mix. Special attention is paid on function of a right ventricle of S. and pulmonary blood circulation. The provision of Trendelenburga (see Trendelenburga situation) at patients with a mitral stenosis is excluded since at it inflow of blood to upper parts of lungs increases that can cause a hypoxia and a fluid lungs. In the postoperative period depending on weight of a condition of the patient and volume of an operative measure can be required prolonged WILLOWS of L.
At insufficiency of the mitral valve with the expressed pulmonary hypertensia anesteziol. tactics is similar developed for patients with a mitral stenosis. Use during anesthesia of vasodilators can reduce at mitral insufficiency in a nek-swarm of degree regurgitation of blood from a ventricle in an auricle and increase emission of blood in an aorta. Use of the anesthetics reducing a peripheral tone of vessels (Ftorotanum) is for the same reason shown.
At a stenosis of the mouth of an aorta sharply hypertrophied left ventricle of S. is insufficiently supplied with oxygen that increases its sensitivity to electrolytic disturbances, and decrease in its distensibility demands providing during operation of quite high volume of the circulating blood. Therefore during the training of these patients for operation diuretics cancel in two days prior to operation. During anesthesia registration of pressure in the left and right auricles, and also in a pulmonary trunk is necessary. It allows to differentiate more accurately hypotension owing to a hypovolemia from hypotension owing to the progressing weakness of a myocardium. Apply the superficial level of anesthesia. It is important to support a sinoatrial rate as any dysfunctions of auricles can sharply worsen a hemodynamics. Emergence of fibrillation of auricles with sharp deterioration in a hemodynamics demands urgent cardioversion. At a rare nodal rhythm effectively fractional administration of atropine. Nodal tachycardia, as well as sinus, korrigirut fractional introduction of a proiranolol.
At moderately expressed aortal insufficiency patients usually well transfer an operative measure. Heavy aortal insufficiency, especially acute, demands careful and careful maintaining anesthesia, in time a cut versatile monitor observation is necessary (see) behind function of cardiovascular system. At the initial stages of operation there is sharp raising of the systolic ABP that is connected with increase in a stroke output, but in the subsequent ABP can sharply decrease. These patients are very sensitive to hypotensive effect of various anesthetics, napr, Ftorotanum, or to vazoplegichesky effect of tubocurarine. In this regard it is necessary to apply vasodilators to reduction of degree of aortal regurgitation with care, providing simultaneous control of changes of pulmonary pressure and cordial emission. Lengthening of a diastole at aortal insufficiency aggravates disturbance of blood supply of bodies and fabrics therefore during anesthesia uses of the drugs causing bradycardia (propranolol, morphine) avoid.
At operations for coronary heart disease (see) anesthesia shall be aimed at providing a myocardium with oxygen, hl. obr. by decrease in his requirement. The direct impact on exchange in a myocardium with reduction of its oxygen requirement is carried out by means of introduction of a proiranolol and Ftorotanum. The last at the same time at patients with left ventricular heart failure and the expressed increase in final diastolic pressure in a left ventricle can cause S.'s dilatation and cause undesirable increase in oxygen consumption by a myocardium. Use of vasodilators (Sodium nitroprussidum, arfo-over, nitroglycerine) is shown to this patients to a large extent that it is especially important at such stages as an intubation of a trachea, a sternotomy, closing of an operational wound, removal from an anesthesia. However and their use also shall be careful as possible considerable decrease in the ABP leads to reduction of coronary perfusion.
At operations for the squeezing pericardis (see the Pericardis), and also a hydrocardia (see) and cardiac tamponades (see) aneste-ziol. providing is made taking into account limited diastolic distensibility of S. and decrease in its stroke output. In view of danger of possible development of bradycardia and decrease in sokratitelny function of a myocardium uses of such anesthetics as thiopental, hexenal, Ftorotanum avoid; with care apply Penthranum. As the main anesthetic it is reasonable to use Ketaminum. In the preoperative period the patient with hron. fluid accumulation carry out therapy to cavities of a pericardium by glucocorticoids and diuretics, and just before operation for reduction of the phenomena of a tamponade and improvement of a hemodynamics use a pericardiocentesis (see the Cardiac tamponade). After removal of an exudate from a cavity of a pericardium compensate the volume of liquid intravascular administration of blood or plasma substitutes. Before anesthesia shall be prepared for immediate use (3-adrenomimetik (Isadrinum, ephedrine, adrenaline), and also ioradre-nalin as the vasoconstrictor interfering intravascular deposition of blood. Prior to the beginning of an introduction anesthesia enough wide is reasonable to establish two intravenous a catheter for control of the central venous pressure and vigorous compensation of a loss of blood and liquid. The main objective is maintenance of intensive inflow of blood to heart (high preloading). Blood and blood-substituting liquids pour under control of the central venous pressure, supporting him on the high level which is approximately corresponding to level before opening of a thorax and a cavity of a pericardium. Nek-rym the seriously ill patient the introduction anesthesia is begun in a sitting position, after an intubation of a trachea of the patient gradually and carefully transferred to horizontal position. During operation exercise monitor control of an ECG, the central venous pressure, the ABP, pressure and a blood-groove in a pulmonary trunk. At excision of a pericardium in case of its expressed fibrosis and calcification different developing of the arrhythmias demanding use of lidocaine, and sometimes and a defibrillator is possible (see the Defibrillation). After removal of a pericardium quite long bleeding can be observed; in such cases enter a hydrocortisone, Trasylolum, aminocaproic to - that, Dicynonum, fibrinogen, a fresh citrated blood, etc.
Anesthesia at catheterization of heart (see), angiocardiography (see) has the features. First, it is necessary to create safety conditions and relative comfort for the patient at diagnostic testing, a cut can be long. Secondly, to choose such technique and tactics of anesthesia, edge would not distort indicators of an endocardiac hemodynamics, gas exchange, breath and iye reduced the diagnostic value of a research of heart. E.g., breath by oxygen, changing gas composition of blood in cardial cavities, complicates diagnosis of dumping of blood through defect in partitions of heart. Similarly can influence the size and an orientation of dumping of blood, to change true hemodynamic indicators artificial ventilation of the lungs. Local anesthesia does not eliminate at the patient, especially at the child, mental reaction (fear, concern, etc.) on a situation, unusual to it, in a diagnostic office. At the same time common fault of inhalation methods of an anesthesia at diagnostic testings of S. is complexity of maintenance of its superficial level and the prevention of a hypoxia during the use of gas mixture without addition of oxygen. Use of not inhalation methods of an anesthesia what apply fractional intravenous administration of 1 — 2,5% of solution of thiopental-sodium to (depressive influence to-rogo can be reduced by breath and a hemodynamics considerably slow administration of drug) is the most reasonable, and at long researches — an anesthesia viadril or hydroxybutyrate of sodium. In all cases the nremedikation in 30 — 40 min. prior to a research sedative and analgetic means is necessary. Satisfactory results are received at anesthesia by means of fractional introduction of small doses of drugs for a neyroleptanalge-ziya. During angiocardiography consciousness of the patient is quickly switched off by means of intravenous administration of Sombrevinum (5 mg/kg), at children for these purposes use Ketaminum, to-ry entered intravenously or intramusculary. In the postoperative period emergence of mental and motor excitement is possible (in the next few hours after the end of a research). It is possible to prevent this excitement use of Seduxenum or Droperidolum.
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Pathology — Birkun A. A. and Chulkov E. G. K to a question of morphology and clinic of tumors of heart, Vopr. onkol., t. 5, JSIs 9, page 287, 1959; Burakovsky V. I. and Konstantinov V. A. Heart troubles at children of early age, M., 1970; In E. A. Hirurgiya's agner of injuries of a breast, M., 1981; Vinogradova O. I. and F and the Dr. at with E. I. Diagnosis and treatment of wounds of heart, Surgery, No. 8, page 70, 1972; Age features of cardiovascular system at children, under the editorship of L. K. Semenova, M., 1978; Gilev ich Yu. S., Askerkhanov R. P. and Karashu-r about in E. S. Wounds of heart and pericardium, Stavropol, 1973; Kalyuzhny R. A. Fiziologiya and pathology of cardiovascular system at children and teenagers, M., 1973, bibliogr.; Kolesnikov S.A., X and r and V. Yu. N and Bershaden-k about D. D. Primary high-quality new growths of heart and their surgical treatment, Vestn. hir., t. 97, No. 11, page 43, 1966; Malinovsky H. N, etc. The closed injury of heart, Minsk, 1979, bibliogr.; An urgent surgery, under the editorship of N. I. Blinov and B. M. Khromov, page 144, L., 1970; Operational surgery, under the editorship of I. Littman, the lane with Wenger., page 232, Budapest, 1981; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 9, page 452, M., 1949; Oskolkova M. K. and Woolf-with about I. N N. Age dynamics of the main functional indicators of the blood circulatory system at healthy children, Fiziol. person, t. 4, No. 4, page 723, 1978, bibliogr.; Petrovsky B. V. Recognition and surgical treatment of primary tumors of heart, Surgery, No. 11, page 74, 1963, bibliogr.; The guide to anesthesiology, under the editorship of T. M. Darbinya-n, page 402, etc., M., 1973; The Guide to cardiology, under the editorship of E. I. Chazov, t. 1 — 4, M., 1982; Tarakanova N. I. and P about d to and S. A N. Wounds of heart and pericardium, Vestn. hir., t. 117, No. 9, page 62, 1976; The Textbook of field surgery, under the editorship of A. N. Berkutov, page 419, L., 1973; Chazov E. I. and Bogolyubov V. M. Disturbances of a heart rhythm, M., 1972; The Specialty surgery, under the editorship of A. A. Vishnevsky and V. S. Levitte, t. 1, page 696, M., 1962; The Emergency heart surgery and vessels, under the editorship of M. E. De Bequi and B. V. Petrovsky, M., 1980; Yurenev P. N., etc. Clinical aspects of diagnosis of primary and secondary tumors of a myocardium and a pericardium, Rubbed. arkh., t. 46, No. 2, page 16, 1974, bibliogr.; In an u d about u at M. e. and. Myxome de I’oreillette droite ^vele par un epanchement pericardique, Coeur Med. interne, t. 16, p. 435, 1977; Cardiac anesthesia, ed. by J. A. Kaplan, N. Y., 1978; Cardiac arrhythmias in the neonate, infant and child, ed. by N. K. Roberts a. H. Gelband, N. Y., 1977; F e i g e n b and and m H. Echocardiography, Philadelphia, 1976; The heart, ed. by J. W. Hurst, N. Y., 1978; To a p a r 1 s G. o. Left artial myxoma, Hellen, cardiol. Rev., v. 19, p. 33, 1978; Madoff J. M. a. Desforges G. Cardiac injuries due to nonpenetrating thoracic trauma, Ann. thorac. Surg., v. 14, p. 504, 1972; Naclerio E. A. Chest injuries, N. Y. — L., 1971, bibliogr.; Paediatric cardiology, ed. by R. H. Anderson a. E. A. Shinebourne, Edinburgh — N. Y., 1978; Prichard R. W. Tumors of heart, Arch. Path., v. 51, p. 98, 1951. Cm. also bibliogr. to St. Heart diseases are inborn, Heart diseases the acquired, Cardiac asthma, Heart failure, Cardiovascular insufficiency.
Mental disorders at heart diseases — V. M. bathhouse attendants, etc. The clinical characteristic of mental disturbances at the patients with the acquired heart diseases who underwent an operation of a mitral commissurotomy, Zhurn. neuropath, and psikhiat., t. 62, century 6, page 916, 1962; Kovalyov V. V. Mental disturbances at heart diseases, M., 1974, bibliogr.; Kremneval. T. The characteristic of disturbances of mental development of children and teenagers with inborn heart diseases of tsianotichesky type, Shurn. neuropath, and psikhiat., t. 73, century 4, page 579,1973; Nevzorova T. And., Degtyareva V. M. and Lebedev R. N. Psychological disturbances at the patients operated concerning rheumatic heart disease, Owls. medical, No. 12, page 56, 1960; Haz? n S. J. Psychiatric complications following cardiac surgery, J. thorac. cardiovasc. Surg., v. 51, p. 320,1966; Picard L. Aspects neuro-psychiatriques de la chirurgie cardiaque a «coeur ouvert», P., 1967, bibliogr.; P i e-ringer W. u. Reisner H. Psycho-pathologische Syndrome nach Herzopera-tionen, Wien. Z. Nervenheilk., Bd 28, S. 246, 1970; Schlange H. Die kor-perliche und geistige Entwicklung bei Kin-deril mit angeborenen Herz-und Gefassmiss-bildungen, Arch. Kinderheilk., Suppl. 47, S. 1, 1962.
L. H. Bisenkov, A. P. Kolesov (damages), V. A. Bogoslovsky (diseases), L. V. Vanina, V. N. Demidov (influence of pregnancy and childbirth on heart), I. E. Galankina, N. K. Permyakov (stalemate» An.), N. D. Grayevskaya (influence of sports activities on heart), V. V. Zaretsky, E. K. Lukyanov, V. I. Makolkin (mt., issl.), V. V. Kovalyov (psikhiat.), G. I. Co-sitsky (physical.), S. S. Mikhaylov (history, comparative anatomy, embr., An., gist.), M. K. Oskolkova (ped.), And. X. Rabkin (rents.), V. A. Saks (biochemical), K. G. Taba-tadze (soldier.), L. V. Shkhvatsabaya (PMC.)