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gradients, viru sabiezējums, abu mitrālo viru vienvirziena kustība, mitralās atveres laukums < 4 cm2. KP un LK dilatācija. Klīniskie simptomi paradās pie atveres laukuma < 2,5 cm2 (N=4-5 cm2), bet pie >1,5 cm2 nav simptomi mierā. Rtg: sastrēgums plaušās, sirds mitrala konfiguracija, barības vada deviācija 1. slīpā projekcijā pa mazo (<6 cm) rādiju. Iedalījums. ·Viegla – mitrālās atveres laukums – 1,6- 2,2 cm2; ·Mērena – 1,0-1,5 cm2; ·Smaga - < 1,0 cm2; ·Kritiska - < 0,8 cm2. Ārstēšanas principi. ·Infekciozā endokardīta profilaxe. ·Reimatisma ārstēšana un profilaxe. ·Konservatīvā ārstēšana: *bradikardizēšana g.k. ar BAB – verapamils, diltiazems (vēlama frekvence mierā < 70/min, pie slodzes - <100/min.). *mirdzaritmijas gadījumā izlem jautājumu kupēt vai nē, ja KP > 5 cm, tad nevajag kupēt. Lieto: antikoagulantius(varfarīns), digoxīnu. *SM ārstēšana ar diurētiķiem un digoxīnu. AKE-I ļ. uzmanīgi, jo tā jau maza pēcslodze un AKE-I mazina izsviedi. Indikācijas operacijai. ·Valvulotomijai – ja nav viru kalcinoze un trombi KP; simptomātiskiem pac. ar viru atvēršanās laukumu < 1,5 cm2.; asimptomātiskiem pac. ar atveri < 1,5 cm2, bet pulmonālo hipertensiju > 50 mm Hg. ·Protezēšanai – simptomātiskiem pac. (NYHA 3-4) un atvēršanās laukumu < 1,5 cm2; pac. ar SM (NYHA 1-2) un laukumu < 1 cm2.
Sirdskaišu vispārējie ķirurģiskās ārstēšanas principi. ·Operācija vairums gadījumos nav indicēta asimptomātiskiem pac. ·Operācija indicēta pie progresējošiem sirds funkciju traucējumiem un/vai tipisku sirdskaišu simptomu parādīšanās 9vairums gadījumu pie SM NYHA 2-3). ·Balona valvulotomiju reti veic pie aortas stenozes , bet var pie mitrālas stenozes, ja nav viru kalcinoze. ·Bioprotezēšana. Priekšrocības: nevajag antikoagulantus, reti tromboembolijas vai jaunām sievietēm, kas vēlas grūtniecību. Mīnusi: īsāks kalpošanas laiks, attīstās primāra viru mazspēja. Bioprotezēsanu parasti veic pac. pēc 60-65 g.v. ·Mehāniskās viru protēzes. Priekšrocības: ilgāk kalpo, labāk jauniem pac. (<40), lieto, ja paredzama ilga dzīve. Lieto, ja citu iemeslu dēl jālieto antikoagulanti. ·Anulloplastija. Indicēta g.k. pie trikuspidālas regurgitācijas, jo bieži tā ir sekundāra sakara ar LK dilataciju, nevis viru bojājumu.

18. AORTĀLA REGURGITĀCIJA – ETIOLOĢIJA, PATOĢENĒZE, KLĪNIKA, DIAGNOSTIKA, INDIKĀCIJAS ĶIRURĢISKAI KOREKCIJAI.
Etioloģija. 1) Viru bojājums: reimatisms; infekciozs endokardīts; iedzimtu bikuspidālu viru deģeneratīvas pārmaiņas, kalcinoze. 2) Aortas sākuma daļas patoloģija: ideopātiska saknes deģenerācija – annuloaortala ektāzija (riska faktori: AH, vecums); Marfāna sy.; aortas aneirisma un/vai atslāņošanās; sifiliss; ankilizējošais spondilartrīts; smaga AH. 3) Akūtai: trauma; infekciozais endokardīts; aortas atslāņošanās. Patoģenēze. Diastoles laikā asinis no aortas daļēji atgriežas KK un sajaucas ar asinīm, kas ieplūst no KP. KK dilatējas. Kmopensatori hipertrofējas KK un saīsinās diastole. Ar lielu spēku izsviestās asinis ­ sist. TA aortā, bet tā kā diastolē sainis atplūst uz KK- Æ diastoliskais TA. Kompensatora perifēro arteriolu spazma. KK dilatācija rada relatīvu mitrālu insuficienci, kas izraisa KP pārslodzi un mazā loka hipertensiju. Klīnika. ·Ilgstoši asimptomātiska. ·KK mazspējas sy. g.k elpas trūkums īpaši naktīs. ·Sāpes sirds rajonā, ko izraisa aortas un vainagartēriju sienas bojajums. ·Ģīboņu lēkmes, bet retak kā pie AS. ·Bāla āda, artēriju pulsācija, kapilāru pulss, tahikardija. Diagnostika. ·Auskultatīvi: *diastolisks troxnis uz aortas viru izklausīšanas vietās (kaķīšu dzirnaviņas), *novājināts 2 tonis, kas uz aortas izkrīt, *Æ diastoliskais
TA, liels pulsa P, *karotīdu deja, *kapilāru pulss (Kvinkes pulss= nagu pulsācija), *galvas pulsācija (Mise sy.), zīlīšu pulsacija, *sistoliskais p kajās > 30 mm Hg lielāks ka rokās (Hila sy.). ·Ekg: KK hipertrofija un pārslodze. ·EhoKg: palielints KK, valvulars vai aortas saknes paplašinājums. Regurgitacijas plūsma caur aortas atveri diastolē. Labas prognozes rādītāji: IF > 55% , KK beigu sistoliskais diametrs <55 mm. ·Rtg – aortāla sirds konfigurācija. Smagas regurgitācijas radītāji: *paroxizmāls elpas trūkums, īpaši naktīs, *­ pulsa P > 100 mmHg, *diastoliskais TA < 50 mmHg, *S3 galops, *KK sistoliskais izmērs >55 mm, IF < 55%. Ārstēšanas prinicipi. ·Infekciozā endokardīta profilaxe. ·Konservatīva th.: *etioloģiska th., *vazodilatatori arī asimptomātiskiep pac., lai perifērija būtu mazāka pretestība: AKE-I, dihidropiridīnu CaKB (nifedipīns), hidralazīns, *digoxīns – tikai pie mirdzaritmijas, *diurētiķi. ·Indikācijas viru aizvietošanai: *SM simptomi (NYHA 3-4) un saglabāta KK funkcija ( IF > 50%); *SM (NYHA 2) ar stenokardiju vai IF > 50%, bet progresējošu KK dilataciju; *operacija vēlama kamēr KK beigu sistoliskais diametrs < 55 mm, IF >55 %; *asimptomātiski pac. ar KK disfunkciju (IF 25-50%) un KK beigu sistolisko P > 55mm.

19. AORTĀLĀ STENOZE – ETIOLOĢIJA, PATOĢENĒZE, KLĪNIKA, DIAGNOSTIKA, INDIKĀCIJAS ĶIRURĢISKAI KOREKCIJAI.
Biežākā izolētā sirdskaite pieaugušiem. Iedalījums: subvalvulāra, supravalvulāra (bieži iedzimta) un valvulāra. Etioloģija. N= trikuspidāla varstule. ·iedzimtu bikuspidalu viru deģeneratīvas pārmaiņas un kalcinoze no lapiņu malām (iedzimtas bikuspidālas viras ir 1-2% iedzīvotāju. Sirdskaite manifestējas ap 40-50 g.v.). ·normālu viru ideopatiska (senīla) hibrokalcinoze (>70 g.v.). ·reimatisms, parasti kopā ar mitrālu sirdskaiti. Lapiņas salīp kopā. ·Infekciozs endokardīts – reti. ·Iedzimta < 30 g.v. Viru deģeneratīvo pārmaiņu riska faktori: hiperholesterinemija, CD, AH, aptaukošanās, ­ jonizētā Ca saturs (hipoparatireoidisms), KSS. Patoģenēze. Sistoles laikā asinis no KK ar grūtībām ieplūst aorta. Katrā sistolē daļa asiņu paliek KK un no KP plūst nākošā porcijā. Rezultāta KK hipertrofējas un dilatējas. Sistole kļūst spēcīgāka un garāka. Asinis caur stenozi iet ar turbulenci un rada aortas poststenotisku paplašināšanos. Klīnika. Ilgu laiku asimptomatiska, kompensēta. 50-80% nav simptomi 2-10 gadus. Pirmie simptomi elpas trūkums, sirdsklauves. Ātri progresē, ja parādās galvenie simptomi: stenokardija (jo koron. as. v. atiet aiz stenozes vietas); ģīboņi; SM – sistoliska un diastoliska. 50% mirst 4-5 gados , ja stenokardija; 3-4 gados, ja ģīboņi; 2-3 gados, ja SM. Elpas trūkums ir pie dekompensācijas. Kompensatori ir bradikardija, Æ TA. Diagnostika. Auskultatīvi: rupjš sistolisks troxnis aortas izklausīšanas vietā un Erba punktā; novājināts 2. tonis (aortalais komponents, jo viras necērtas ciet, pulss – lēns, vājāks); S3 galops; sistoliska drebēšana; pastiprināts galotnes grūdiens pa kreisi un uz leju. Ekg: Kk hipertrofija un pārslodze, biežāk sinusa ritms, extrasistoles, blokādes. EhoKg: aortālo viru sabiezējums, nepilnīga atvēršanās, Æ aortas atveres laukums, KK hipertrofija, ­ sistoliskair gradients starp KK un aortu, relatīva mitrala regurgitācija. Rtg: aortāla sirds konfigurācija. Iedalījums:

Smaguma pakāpe Vidējais gradients Aortas atveres laukums(N= 3,0 – 4,0 cm2)
viegla < 35 mm Hg 1,0 – 2,0 cm2
mērena 36 – 50 mm Hg 0,75 – 1,0 cm2
smaga > 50 mm Hg < 0,75 cm2

Smagu stenozi var iedalīt: *kā kompensētu ar N izsviedes frakciju, *dekompensētu ar Æ izsviedes frakciju. Ja pastāv ilgi, var pievienoties mitrāla insuficience. Ārstēšanas principi. ·Ja nav simptomi – neārstē. Veic infekciozā endokardīta profilaxi. ·Konservatīvā th.: *etioloģiska th. *nitrāti, diurētiķi pie SM un stenokardijas *AKE-I, vazodilatatori relatīvi K/I (­ģīboņus, pēkšņu nāvi, būs smaga hipotensija). ·Indikācijas viru aizvietošanai; *ja ir simptomi noteikti operē, med. nedod, dod tikai pie komplikācijām *smaga ao. stenoze , ja parādās klīnika *smaga stenoze pac., kam veic koronaro šuntēšanu vai citu viru operāciju. *sistoliskais gradients > 50 mm Hg un/vai viru laukums < 0,5 cm2. *valvuloplastijai (papleš vaļa) ir šauras indikācijas un to var veikt nestabiliem pac. pirms viru aizvietošanas. *Ja pac. >40 g.v. pirms operacijas veic koronarogrāfiju.

20. PRIEKŠKAMBARU, KAMBARU STARPSIENAS DEFEKTS – HEMODINAMIKAS TRAUCĒJUMU RAXTURS, KLĪNIKA, DIAGNOSTIKA, ĀRSTĒŠANA.
Priekškambaru starpsienas defekti. Izolēts PK defekts 7-8%, kombinēts- 25-40%. Atkarībā no embrionalās izcelsmes ir primārs un sekundārs (85-98%). Var būt: centrāls, augšējais, apakšējais, kopējs PK, koronārais sinuss. Embrionālā periodā: LP® KP® KK. Pēc dzimšanas: ­ P KP (sāk elpot)® slēdzas ar varstuli = N. Hemodinamika pie defekta. Pēc dzimšanas foramen ovale aizveras no kreisa priekškambara puses ar speciālu vārstuli. Ja tā slēdzas nepilnīgi, veidojas sirdskaite- persistējoša ovālā atvere. Embrionalā periodā var būt traucēta arī ātriju starpsienas veidošanās, tad veidojas: *ostium primum, kas bieži kombinējas ar AV viru attīstības traucējumiem un izpaužas agrīni *ostimu secundum, kas ilgi ir asimptomatisks. Caur starpsienas defektu asinis priekškambaru sistolē plūst no KP un LP ® LK ® plaušu artērijām ® plaušu vēnām ® KP ® LP. Rodas patoloģisks asinsrites loks, kuru veido mazais loks un KP. Relatīvi maz sainis izplūst caur KK. Slimnieki ir bāli, atpaliek attīstība. PL, LK, plaušu artērijās nonāk papildināts asiņu daudzums ® LP un LK dilatējas, palielinās plaušu stumbra lūmens, bet tā reakcija mainas minimāli. Veidojas plaušu stumbrarelatīva stenoze un vārstuļu relatīva insuficience. Vēlīni pieaug pretestība plaušu artērijās (spazmas® skleroze) un ­ P plaušu artēriju sistēmā lidz ar to arī LK un LP. P LP pārsniedz P PK, veidojas pretējs šunts. Venozās asinis plūst no LP un KP uz KK® lielo sainsrites loku. Klīnika. Manifestējas pirmā gada laikā 40%, parējiem līdz 5 g.v. Cianoze, izteikts elpas trūkums, nespēks, audu hipoxija, bungvālīšu pirksti, hroniski bronhīti, LK dilatācija un hipertrofija. Bieži ARS. Diagnostika. ·Sirds robeža nobīdīta pa labi. ·Ir paplašināts asinsvadu kūlītis ·Auskultācija: *mezosistolisks troxnis 2-3 ribstarpā pa kreisi, *šķelts un pastiprinats 2 tonis uz truncus pulmonalis, *sistolisks troxnis 2, 3 ribstarpa pa kreisi – no LK plūstot caur stenozēto plaušu artērijas atveri. ·Ekg- dextrogramma., P-pulmonale, daļēja vai pilna labas kājiņas blokāde. Ārstēšana. Operācija ar defekta slēgšanu.
Kambaru starpsienas defekts. Biežāk kā ātriju. 15-30% biežāk sastopamā sirdskaite. Klasifikācija: populārākā ir pamatota uz anatomisko lokalizāciju un saistīta ar sirds vadīšanas


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Curtislom 1 28
gegheex

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Curtislom 1 29
hodrsyb

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Douglasst 1 29
fozohnc

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Curtislom 2 2
gwnpdpg

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Curtislom 2 2
nlmjgca

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Thomaspt 2 5
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Richardma 2 6
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Richardma 2 6
thxbzmm

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Richardma 2 7
loxggeo

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Curtislom 2 8
zlghvpy

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Richardma 2 8
ptnqmgz

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Curtislom 2 9
jslzdha

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NastyaOa 2 14
Приветствую! Админы \ модеры - Как это понимать что за ИНТИМНОЕ фото в моем профиле? Вот: gudrinieks.lv/user/foto_307
Я такого не загружала, это не я!


EugeneWob 2 19
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RichardSiz 2 19
gejwyxs

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Josephrig 2 21
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Josephrig 2 21
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Josephrig 2 21
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Richardma 2 27
tpwwzpr

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RonaldMa 2 27
zynvzay

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Roshe Run Femme Bleu Marine
Occhiali Ray Ban 2016 Tondi
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Curtislom 2 27
dwtpvvi

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Richardma 2 27
gnljcxv

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Curtislom 2 27
qfewdca

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Curtislom 2 27
nnpwisz

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Nike Free 5.0 V4 Print Womens Running Shoes
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Lorriefah 4 22
Hello, guys!
Free to buy XRumer 12.0.20??
It is the most popular program for internet-marketing.
Thanks.