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Valvulopatii

Cebotari Liudmilarezidenta an.II,

neurologie

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CARDIOPATII VALVULAREDATE GENERALErezulta din remanierea scleroasa a aparatului valvular (valve, comisuri, cordaje, pilieri,inel) izolata sau asociata

cauzede remaniere: endocardita reumatismala, infectioasa, factori degenerativi,distrofici (sdr.Marfan, Ehler-Danlos)profil hemodinamic:

stenoze valvulare rezistenta la evacuarea sangelui dintr!o camera in alta saudintr!o camera a cordului intr!un vasinsuficiente valvulare deplasare retrograda a sangelui prin valvele

incompetente dintr!o cavitate a cordului in alta sau dintr!un vas in cordleziuni combinate (boala mitrala, aortica)

debutul: acut (endocardita infectioasa acuta, infarctul valvei mitrale, I"# cu necroza siruptura de pilier) sau lent (endocardita reumatismala)Dianosticul valvulo!atiilor"1. examen clinic 4. ecocardiografie (eco M, eco B, eco Doppler

!. E"#, mecanografie $. cateterism, cineangiografie, coronarografie

%. examen radiologic &. teste de efort

# $ Dianosticul com!let al unei valvulopatii include:$tipul $ forma$etiopatogenia $ stadiul, severitatea disfunctiei cardiace (clasa %&'#)

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%TENO&A 'ITRALA (%')reducerea suprafetei orificiului mitral (N * +$,cm- ) cu. /012prin:! scleroza valvulara ! retractia cordajelor! sutura comisurilor ! calcificari"lasificare (dupa gradul de se'eritate%' lara (% . 324$5cm-)! presiunea capilara pulmonara 6 50mm7 si cea din art. pulmonara 6 8/mm7 (laefort)! bine tolerata%' mo9erata (% * 32,$328cm-)! presiunea capilara pulmonara 6 5/mm7 presiunea din art. pulmonara 6/0mm7(laefort)! apar primele semne ale ", conditionate de * presiunii in # si in teritoriul venocapilarpulmonar si de + volumului sistolic%' severa (% 6 323 cm-)

! presiunea capilara pulmonara 5/$80mm7 (la efort. 80mm7) presiunea din art.pulmonara /0mm7 (la efort)! la o presiune -idrostatica .80mm7 in capilarul pulmonar/#%' foarte severa (% * 02: cm-)! presiunea capilara pulmonara +0mm7 pres.din art. pulmonara . ,0mm7! edem pulmonar acut de efort (frecvent)

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Edemul pulmonar acut in stenoza mitrala

! edem interstitial pulmonar (dispneea mitrala) transsudarea lic-iduluiplasmatic din capilarele pulmonare in alveole

! presiunii venocapilare vasoconstrictie arteriolara si rezistentelor'0/ fi1a dilatarea si decompensarea V2 ameliorarea dispneei! simptomatologia " depinde degradul de distensibilitatea #

Etiologia stenozei mitrale (neprecizata in !)* dintre cazuri

! 3## (3eumatism articular acut) ! mi1om 4 tromboza #! poliartrita reumatoida ! calcificarea inelului mitral! congenitala (2# 5 " sdr.+utembacher)

"lasificare semiologica

! " prin leziune valvulara oranica! " functionala(2V, 6#V gr.III, I#, I" severa, mi1om si tromboza # )

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imptomatologie functionala

dispnee de efort, progresiva ortopneedispnee paro1istica nocturna, edem pulmonaracut

semne de decompensare cardiaca dreaptatuse seaca, accentuata de efort, -emoptiziidureri precordiale, jung-iul auezdisfagie, disfonie, palpitatii

Examenul fizicIns!ectie ! nanism mitral, facies mitralpuls jugular cu accentuare presistolicapulsatii sistolice ale jugularelor, semnul/arzerbataile art. pulmonare (sp.II!III i.c. parasternal

stg)

Pal!are ! soc ape1ian slabvibranta mitrala a luiBardfreamat catar diastolicpulsatiile art. pulmonare dilatatepulsatia V2 (epigastru)

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Ascultatie&3accentuat, clacmentul de deschidere a mitralei, &5accentuat la pulmonaradedublare de &5uruitura diastolica, suflul presistolic(in conditii de ritm sinusal)suflul de insuficienta tricuspidiana organofunctionalaraluri pulmonare crepitante si subcrepitante (plaman de staza)4 abolirea murmurului vezicular si submatitate (transsudate sau e1sudate de insotirea infarctelor pulmonare)

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Explorari paraclinice

Ra9iosco!ia si ra9iorafia toracica: 0x de fata: bombarea arcului

mijlociu stang, V normal4redus cavolum

2D 3 pasa baritat esofagian:

devierea esofagului, ingustareaspatiului retrocardiac (# dilatat) pozitie lateralareducerea spatiului

retrosternal (prin 'V2) calcificari ale valvelor mitrale

plaman cu aspect de staza venoasasi interstitiala (umbre -ilareaccentuate, liniile5erle6 2siB,aspecte de -emosideroza,vizibilitatea scizurilor)

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CORD 'ITRAL"a)A% marit2contur 9re!t festonat; b)CORD 'ITRAL"a)A% marit2contur 9re!t festonat; b)in OAD$am!renta esofaiana e

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ECG" / mitral, 'V2 si '#2onocar9iorama(intervalul &5$CD'2 in relatie in'ersa cu

severitatea ")A!e

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INSUFICIENAMITRAL

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Clasificare

Cronic

Acut

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Etiologie

RM cronic1. RAA

. !V"#. Cardiopatia isc$emic%&. Funcional% ' dilatarea VS(. Calcificarea degenerativa a inelului mitral

). E*+. C",-. Cardiopatiile congenitale/. Colageno0e

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Etiologie

RM acut

1. E*

. *"A ruptur% mu2c$i papilar#. *sc$emie acut% mu2c$i papilar&. 3raumatism toracic(. !atologia prote0ei valvulare mitrale

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Fiziopatologie

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Fi0iopatologie

RM acutAS mic 4 presiune5

RM cronicAS mare 4 presiune 6

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IN%UICIENTA 'ITRALA (I')

/emodinamica 7M!reflu1 sistolic din V in #presiunii in # si in venele pulmonare '0/

IV2 prin suprasolicitare de rezistenta

sindrom de debit cardiac mic si suprasolicitare devolum a V in diastolaIV

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Examen obiecti'Ins!ectia" cianoza la buze, nas, e1tremitati (in formelesevere)Pal!area" ! soc ape1ian coborat, perceput pe osuprafata intinsa ! freamat sistolic ! e1pansiunea de volum a # (sp. II!III i.c.stang, parasternal)Ascultatiasuflu sistolic apexian (in 7jet de vapori8):-olosistolic4protomezo!4mezotelesistolicscaderea amplitudinii &3acoperirea &5 sau dedublarea &5prin precesiuneacomponentei aorticeaparitia &8, urmat de un scurt rulment de debit ("

relativa)

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3a9lou clinic

RM acut:; insuficien% cardiac% acut% 4 E!A

RM cronic simptomatologia 9olii de 9a0% asimptomatici timp ndelungat sta0% pulmonar%: dispnee de efort< ortopnee

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Fi0iopatologie

-traciune pe muchii papilari ischemie aritmii ventriculare

-elongare / rupere cordaje R

-disuncie sistem nervos vegetativ

-moartea su!it

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3a9lou clinic

!alpitaii

Durere precordial%

Dispnee

Fatiga9ilitate

3ul9ur%ri neuropsi$ice

"icroem9olii cere9rale

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Examen o9iectiv

a* +nral!

modific%ri sc$eletice asociate

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Examen o9iectiv

%* Aparat cardiovascular

Ascultaie:

clic #0osistolic4' R": suflu sistolic

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Examene paraclinice

"* EC+)* Ecocardio.ra'i-* Cattris# cardiac

/* Studii lctro'i0iolo.ic1* Studii radioi0otopic

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Examene paraclinice

"* EC+ ' nespecific

3est de efort fals po0itiv"onitori0are ,olter ECI

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Examene paraclinice

)* Ecocardio.ra'i

Criterii de diagnostic :1. D modul " ' deplasarea posterioar% me0o'telesistolic%

? mm a uneia am9elor cuspe valvulare =7cui9 derndunic%8>< sau deplasarea posterioara $olosistolic% ? #mm a am9elor cuspe mitrale = J$amac7>B. modul D ' c%derea sistolic% n AS a uneia am9elorcuspe mitraleB

#. R" ' Doppler spectral 2i color

' redundana valvular% mitral% ' grosimea cuspelor mitrale ?( mm n diastol%.

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Ecocardiografie

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Examene paraclinice

/* Cattris# cardiac

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Examene paraclinice

1* Studii lctro'i0iolo.ic

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Evoluie< complicaii< prognostic

Co#plicaiil (7M !

' moarte su9it% cardiac%' insuficiena mitral% progresiv%'ruptura cordaGelor tendinoase

'evenimente em9olice cere9rale'endocardita infecioas%

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3ratament

pacieni asimptomatici

prezena R palpitaii" dureri precordiale -!locante

evenimente em!olice - antiagregare

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IN%UICIENFAIN%UICIENFAAORTICAORTIC

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6'inii

(r0na 'lu,ului diastolic rtro.rad din aort8n 7S9 .nrat d inco#ptna aparatului

valvular aortic

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Etiolo.iRA cronicRA cronic RA acutRA acutCardita ru#atis#alCardita ru#atis#alSi'ilisSi'ilisAortita Taunctiv

?sindro#ul Mar'an9 sindro#ul E4lrs;?sindro#ul Mar'an9 sindro#ul E4lrs;6anlos9 osto.nsis i#pr'cta@6anlos9 osto.nsis i#pr'cta@Cardiopatiil con.nitalCardiopatiil con.nital??7alva aortica7alva aortica

%icuspida%icuspida99 6'ct sptal vntricular6'ct sptal vntricular99aanvris#nvris#ddsinus 7alsalvasinus 7alsalva@@

3olil d cola.n3olil d cola.nNcro0a #dio;c4istica a aortiNcro0a #dio;c4istica a aorti

TA sist#icTA sist#icArtriosclro0aArtriosclro0a6.nrscn6.nrscna #i,o#atoasa #i,o#atoasEndocardita in'cEndocardita in'cioasioas

Endocardita in'cEndocardita in'cioasioasCardita ru#atis#alCardita ru#atis#alRuptura sinusului 7alsalvaRuptura sinusului 7alsalva6isc6iscia d aortia d aortTrau#atis#ul toracicTrau#atis#ul toracic

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Fi0iopatolo.i

A* Nor#al:3* RA acut =total stroKe volum 5< forLard stroKe volum M< NVED! 5 5>C* RA cronic co#pnsat =eccentric NV,< EDV 5< total stroKe volum 5< forLard stroKe volum 5< NVED! normal>6* RA cronic dco#pnsat=EDV 5< EF M< total stroKe volum M< forLard stroKe volum M>E* (ostprot0ar aortic

IN%UICIENTA AORTICA (IA)

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IN%UICIENTA AORTICA (IA)

Etiologie

I# oranica: congenitala si dobandita

I# functionala: dilatari importante de V sau de aorta

imptome functionale

senzatie de pulsatie puternica, cu batai ale vaselor de la baza gatuluiameteli, cefalee, acufenedispnee si angina de efort (dupa decompensare)

Examen obiecti'

Ins!ectie" soc ape1ian amplu, etalat, deplasat in sp.VI!VII i.c.stg., in afara l.m.c.Pal!are" $ socul ape1ian da senzatia loviturii unei mingi de tenis ! galop ventricular (in protodiastola)Ascultatie

suflu diastolic(sp.II i.c.drept, parasternal si sp.III i.c.stg., cu propagare descendenta)uneori se asculta in sp.I i.c.dr. (dilatare anevrismala a aortei)manevre de facilitare a ascultatieisuflu sistolic organo-functional(prin debit crescut)in functie de severitatea I#:rulmentul 8oster sau rulmentul 2ustin-8lint&3 normal4diminuat &5normal4diminuat

clicuri mezosistolice (aorta elastica, distensibila)

if i

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emne periferice

paloare caracteristica-iperpulsatilitate, dans arterial carotidian

miscarile capului in ritmul pulsului (semnul2lfred de Musset)pulsul amigdalian si al luetei (semnulM9ller), -ippus pupilar (semnul+andolfi)-iperpulsatilitate la nivelul bratului (semnul mansetei sau al ciocanului de apa)pulsatia piciorului la pozitia picior peste picior (semnulabrazze)puls capilar (semnul :uinc;e)TAde tip di'ergent,puls "orrigan(celer et altus)

ascultatia fara compresiune la femurale si carotide: dublul ton arterial

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p

E

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CORD AORTIC"'ARIRE A VENTRICULULUI %TING

%I ECTA&IE AORTICA IN IN%UICIENTA AORTICA

PA OA%

6uton aortic

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CORD TIPAORTIC"IN%UICIENTA AORTICA

V% V%V%

OA%PAPA

6uton aorticproieminent, proiectatdeasupra claviculei

>olful pulmonareiadincit

2iamlongitudina

lcardiacmarit

#o ascendentaectaziata,batanta

#oascendenta

ectaziata

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%TENO&A%TENO&AAORTICAORTIC

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6'inii

rducra ariiori'iciului valviaortic cu

o%strucia >ciivntriculului stBn.i .nrara unui

.radint prsionalsistolictransvalvular

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Etiolo.i

A. Valv% Ao normal%O. S Ao congenital%C. S Ao reumatismal%D. S Ao calcificat%

E. S Ao degenerativ%

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Etiolo.i

a. V Ao 9icusp%9. V Ao 9icusp%< cu

cuspe inegale

c. V Ao tricusp% 4calcific%ri 9a0ale

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Fi0iopatologie

%TENO&A AORTICA (%A)

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Date generale

realizeaza reducerea suprafetei orificiului aortic cu 5/1 (% 8$+cm- ) baraj laejectia V

cuspele aortice sunt eversate, in dom, cu comisuri fuzionate

Etiologie

conenitala (subvalvulara, valvulara sau supravalvulara)9oban9ita: 3##, ateroscleroza, mediocalcozaM=nc;eberg, endocardita, lues

"onsecinte hemodinamice* timpul de ejectie a sangelui din V in aorta, * viteza flu1ului, * presiuneatelediastolica in V'V de tip concentric (de baraj)

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Ta%lou clinic

!erioad% de laten%

3riada clasic%:

' An.in pctoral

' Sincop la 'ort' Insu'icina cardiac

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E,a#n o%ictiv

pulsus parvus et tardus

; 2oc apexian dublu2i suflu sistolic(sp.IIi.c.dr.parasternal, cu iradiere 7in clepsidra8)

Ascultaia cordului : clic de eGecie aortic su'lu sistolic d >ci (in protosistola)

P Suflu diastolic de regurgitare aortic% clicuri de eectie &5 normal 4 dedublat

parado1al &+(in # severe)

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E,a#n paraclinic

"* EC+)* R, toracic-* Ecocardio.ra'i/* Cattris# cardiac

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E,a#n paraclinic

"* EC+

' fore terminale p n V1

' ,VS

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E,a#n paraclinic

)* R, toracic

dilatare aort%< poststenotic VScalcific%ri valvularesta0% pulmonar%

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R,* toracic

' dilatare poststenotic%

Ao ascendent%' ,VS' semne sta0% pulmonar%

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R,* toracic

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E,a#n paraclinic

-*Ecocardio.ra'i

Diagnostic po0itiv< de severitate< etiologic< funcional

SA svr!' desc$iderea valvei aortice mm' planimetrie orificiul aortic @

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E,a#n paraclinic

/* Cattris# cardiacpentru intervenia c$irurgical%:

' 9oal% coronarian%Q' RAo coexistent%

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6ia.nostic po0itiv

E,a#n o%ictiv

&

Invsti.aii paraclinic

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6ia.nostic di'rnial

*nsuficiena mitral%*nsuficiena tricuspidian%

C",-Defectul septal ventricularB

S1 S

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Evolui9 co#plicaii9 pro.nostic

Co#plicaiil SA:moartea su9it%angin% pectoral%

sincop%,3!< *nsuficien% cardiac%fi9rilaie atrial%trom9o0% atrial% stng%< trom9em9olism

sistemicendocardit% infecioas%recuren% reumatismal%

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Evolui9 co#plicaii9 pro.nostic

Evoluia natural%

T t t

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Trata#nt

A* Trata#nt #dica#ntos

3* 7alvuloplastia aortic prcutan cu%alona

C* Trata#nt c4irur.ical6* (ro'ila,ia EI

T t t

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Trata#nt

A*Trata#nt #dica#ntos!

' pacieni asimptomatici' vasodilatatoare Q' tratamentul insuficienei cardiace

' fi9rilaie atrial%

T t t

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Trata#nt

3* 7alvuloplastia prcutan cu%alona' metod%' indicaii

T t t

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Trata#nt

C* Trata#nt c4irur.ical

' indicaii' metode: comisurotomie aortic%

prote0area valvular% aortic%

autotransplant pulmonar

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%TENO&A%TENO&A

TRICU%PIDIANTRICU%PIDIAN

D fi ii

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Definiie

o%strucia 'lu,ului san.uin transtricuspidian 8ncursul u#plrii diastolic a 769 cu instalara unui.radint prsional transvalvular diastolic

! reducerea suprafetei orificiului tricuspidian baraj la golirea#2 in V2 * presiunii in sistemul cav

Eti l i

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Etiologie

1. RAA

. Atre0ie congenital% de valv% tricuspid%#. Sindrom carcinoid

&. 3umori AD

(. Fi9ro0a endomiocardic%

). Vegetaii V3+. Nupusul eritematos sistemic

3 9l li i

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3a9lou clinic

de9it cardiac : astenie< fatiga9ilitate

discomfort a9dominal 2i anorexie secundare congestieiviscerale< $epatomegaliei de sta0% 2i rev%rsatuluiperitoneal

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Examene paraclinice

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Examene paraclinice


%TENO&A TRICU%PIDIANA (%T)

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E

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Examene paraclinice

R, toracic

Diagnostic po0itiv

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Diagnostic po0itiv

E,a#n o%ictiv

&


3ratament

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3ratament

A*Trata#nt #dica#ntos3*Trata#nt c4irur.icalC*(ro'ila,ia EI

3ratament

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3ratament

C* Trata#nt c4irur.ical

' *ndicaii: gradient presional diastolictranstricuspidian ? &'( mm ,g

' metode: prote0area cu valv% 9iologic%

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IN%UICIENFAIN%UICIENFA

TRICU%PIDIANTRICU%PIDIAN

Definiie

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Definiie

pr0na unui 'lu, san.uin sistolicrtro.rad din 76 8n A69 ca ur#ar ainco#ptni aparatului valvular

tricuspidian

Eti l i

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Etiologie

FuncionalCau0e rare:

E* =utili0atorii de narcotice pe cale i.v.> organica: endocardita, traumatism toracic, valvulotomie pulmonara> functionala: '0/ severa, dilatatia idiopatica a art. pulmonare

imptomatologie si examen clinic

asimptomatica 4 dispnee si fatigabilitate de efortsemnele bolii de baza (in I/ functionala)semne de insuficienta V2, cu simptome dispeptice asociate

pulsatii in aria pulmonara&5 dedublat larg, accentuarea componentei pulmonaresuflu diastolic descrescendo, suflu sistolic eectional si suflu sistolic de insuficientatricuspidianaExamene paraclinice

E

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*nsuficiena pulmonar%

; funcional%' ta9lou clinic dominat de afeciunea primar%

Examene paraclinice

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Examene paraclinice


Diagnostic po0itiv

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Diagnostic po0itiv

E,a#n o%ictiv

&


3ratament

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3ratament

Trata#ntul a'ciunii pri#ar

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PROTE&EPROTE&E

VALVULAREVALVULARE

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; "ecanice

; Oiologice

!R-3EE "ECA6*CE

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cu %il #onodisc cu ) discuri

!R-3EE "ECA6*CE

/3B/3B0

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Avanta>!

' durat% lung%

/3B/3B0

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60avanta>!

anticoagulare

permanent%eficient%

/3B/3B0

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Indicaii!

' pacieni )( +@ ani

' pacieni care necesit%tratament anticoagulant

' pacieni cu insuficien% renal%cronic%

/3B/3B0

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/3B/3B0ICIC; Valv de porc

; Valv din pericard bovin, etc.

Clasificare

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Clasificare

; Autograft

; Autolog =autogen>; ,omograft =alograft> ' umane

; ,eterograft =xenograft>

tro.ra't?,no.ra't@

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?,no.ra't@

Valv de porc- Hancock I i II

- !arpentier-"dwards

- Intact

Valv din pericard bovin

- !arpentier-"dwards

- Ionescu-#$iley

Valv de porc fr stenturi

- %oronto #&V

- 'reestyle

/3B/3B0ICIC

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Avanta>!

'$emodinamic% apropiat%de cea normal%'6u anticoagulare

/3B/3B0ICIC

/3B/3B0ICIC

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60avanta>!

'degenerea0%=durat% medie )'+ ani>

/3B/3B0ICIC

/3B/3B0ICIC

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Indicaii!

'vrstnici

'femei tinere ce dorescsarcin%' contraindicaii detratamentanticoagulant

' necomplian% la tratamentanticoagulant' prote0area valveitricuspide

/3B/3B0ICIC

/3B/3B0

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/3B/3B0

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Dar'arinINR );-

Dar'arinINR )91 -91

Aspirin1 " #.

(ri#l - luni dupinsria prot0i & &

6up pri#l - luni

7alv aortic & &7alv aortic & risc & &7alv #itral & &7alv #itral & risc & &Dup ghidul ACCA!A " 1##$

!R-3EE O*-N-I*CE ' A63*C-AITNARE

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Dar'arinINR );-

Dar'arinINR )91 -91

Aspirin1 " #.

(ri#l - luni dupinsria prot0i & &

6up pri#l - luni

7alv aortic &7alv aortic & risc &7alv #itral &7alv #itral & risc & &Dup ghidul ACCA!A " 1##$

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2I9%CDII 22I9%CDII 2 /3B/3B0

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II* Tro#%#%olis#III* #ora.ii #a>orI7* Endocardita7* An#ia 4#olitic


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3rom9o0a de prote0%


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Examinare Doppler

B. regurgitari trans/paraprotetice

(! Ideal-TEE) C. performanta "gradul #T$ restante

PROTEZE VALVULAREE

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Disfunctia de prote%a (Disfunctia de prote%a (TEE)

&. 'ea paraprotetic (regurgitare mitrala paraprotetica)! examinare optima in parasternal ax scurt

B. Tromo%a prote%ei* completa/incompleta*

modi+care ,sape anelopa/

0uxmetrie Doppler

C. Endocardita infectioasa*leaegetatie/acese periinelare

D De>iscenta !rotezei (!ier9erea stabilitatii !rotezei)*reuritari valvulare severe

E %tenoza !rotezei


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NeaK'uri paravalvulare


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1unctionalitatea prote%ei*gradient maxim/mediu transprotetic

arie functionala a protezei

54814933-valvulopatii (1)

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