curs stenoza aortica 2012
TRANSCRIPT
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Stenoza Stenoza aorticaaortica
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Stenoza aorticaStenoza aortica
• Etiologie• Consecinte hemodinamice • Manifestari clinice• Evaluare paraclinica• Istorie naturala, prognostic• Aprecierea severitatii• Tratamentul chirurgical/interventional
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Stenoza aortica (SA)Stenoza aortica (SA)
• SA supravalvularaSA supravalvulara
• SA valvularaSA valvulara
• SA subvalvularaSA subvalvulara
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I. Stenoza supravalvulara
rara– morfologic
•clepsidra•membrana•hipoplazia aortei ascendente
– leziuni asociate in 2/3 cazuri•Sindrom William’s
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Sindromul William’s
– SA supravalvulara– facies “elfin”
(spiridus)– hipercalcemie– stenoza pulmonara– hipoplazie de aorta– stenoze vasculare
»renale, celiace
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II. Stenoza aortica subvalvulara
• 15% din obstructiile congenitale in LVOT
• membrana este sub sigmoidele aortei
• uneori atasata de VMA– IM si IA
• asociata uneori cu– hipoplazia inimii stg– CMH obstructiva idiopatica
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Stenoza aortica valvulara
Etiologia
65 ani – stenoza aortica degenerativa
Tineri – stenoza aortica congenitala
Stenoza Ao post-reumatismala = rara
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- valva unicuspa
SA valvulara congenitala
- valva bicuspa
- valva tricuspa
traumatism hemodinamic valvular
- fibroza
- calcificare
Agravarea gradului SA la adult a SA
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- disruptie formarea cuspelor Ao- disruptie formarea cuspelor Ao
- deficit sinteza fibrillina-1
Bicuspidia aortica
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•cea mai frecventa forma de SA congenitala•cea mai frecventa anomalie congenitala
cardiaca (0,5-2%)•3/1 raport incidenta B/F•nu este stenotica in prima copilarie• evolutie cu fibroza valvulara si calcificari
– calcificarile valvulare aortice apar precoce (~40ani) iar cele tricuspide la > 65 ani
poate asocia •6% coarctatie de aorta•hipoplazia de VS
Bicuspidia aortica
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Bicuspidia aortica asociaza
Bicuspidia aortica asociaza
- reducerea suportului
structural al peretelui Ao
- dilatatie crosa Ao
>38mm – (58% cazuri)
risc de disectie Ao tip I (9 - 28% cazuri)
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Stenoza aortica- post reumatismala
Sigmoide valvulare
- ingrosate,
- fibrozate,
- comisuri comisuri fuzionatefuzionate,
- depunere calciu
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SA valvulara dobandita
• postreumatismala• valve ingrosate, retractate, comisuri fuzionate,
depuneri de calciu pe suprafata valvulara• depuneri de calciu pe tricuspida• SA stransa – simptomatica la 20 – 30 anisimptomatica la 20 – 30 ani
• “degenerativa” cu valva aortica bicuspa• valve ingrosate, depuneri de calciu de la baza
valvelor (limiteaza de la acest nivel miscarea valvulara), comisurilor nu fuzioneaza
• SA stransa – simptomatica la ~ 50 anisimptomatica la ~ 50 ani• “degenerativa” cu valva aortica tricuspa
• factori favorizanti (asociati)– HTA, dislipidemia, daibetul, varsta
• valve ingrosate, depuneri de calciu pe suprafata valvelor si comisurilor nu fuzioneaza
• SA stransa – simptomatica la 70 anisimptomatica la 70 ani
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SA calcifica
SA congenitala
SA reumatismala
Depozit calciu
Depozit calciu
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Factori asociati cu progresia leziunilor Factori asociati cu progresia leziunilor degenerative degenerative
- HTA - creste riscul cu 20%
- varsta - dubleaza riscul cu decada
- LDL crescut - Lp (a) crescut - diabetul
- fumatul
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SA – evolutie epidemica
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Modificarile hemodinamice in SAModificarile hemodinamice in SA
•depind de:
•severitatea SA
•leziunile asociate valvulare si coronariene
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Modificarile hemodinamice in SAModificarile hemodinamice in SA
HVS concentrica prin incarcare de presiune»miocite hipertrofiate, proliferare
fibroblastica si de colagen– disfunctie distolica
»cresterea PTDVS in SA severa si scaderea PSAo, determina perfuzie coronara deficitara si ischemie miocardica cu coronare normale
– disfunctie sistolica»SA stransa cu incarcare de postsarcina si
HVS insuficienta pentru mentinerea FE determina scadere FE, ce se normalizeaza dupa protezarea aortica
»disfunctia intrinseca miocitara cu FE < ce nu se normalizeaza dupa protezare aortica
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Manifestari clinice prin SA
• Angina pectorala - efort Angina pectorala - efort
• Sincopa - efortSincopa - efort
- 2/3 pacientii cu SA critica
- boala coronara asociata?
• vasodilatatie sistemica la efort
debit cardiac nemodificat
• malfunctie baroreceptoare
• Moarte subita Moarte subita
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I. Evaluarea corecta a simptomelor pacientului cu SA
• DispneeaDispneea – Excluderea BPOC etc…– BNP pentru IVS
• Sincopa Sincopa – Eliminarea altor cauze
• Angina Angina – Eliminarea bolii coronare
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Istoria naturala a SA
• IC reduce speranta de viata la 2 ani
• Sincopa reduce speranta de viata la 2 – 3 ani
• Angina reduce speranta de viata la 5 ani
• Rata de evenimente in SA severa asimptomatica de 1-2% pe an
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Manifestari clinice prin complicatii
• IVS - dispnee - efort, paroxistica nocturna • Embolii sistemice - microembolii calcare
• Endocardita infectioasa
• Sangerare gastrointestinala - angiodisplazia colon
drept
• Disectia de aorta
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Examen fizic • Examenul cordului
- zgomote:Zg1 normal
Zg2 - diminuat/absent cu exceptia SA congenitale
- dedublat cand prezent semnifica mobilitatea sigmoidelor
Click ejectie aortica (0,06s dupa Zg1) - valva flexibila
- freamat sistolic aortic – nu este indicator de SA severa
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• Suflu sistolic focar aortic
- iradiere a.carotide, varf, intreaga arie precordiala
- intensitate maxima - focar aortic, nu coreleaza cu severitatea SA
- caracter de ejectie : incepe inainte Zg1, se termina inainte de Zg2, varf tardiv al suflului - SA severa
- transmis la mitrala cu “arie de liniste” fenomen Gallavarden; se diferentiaza de suflul de IM deoarece
nu creste dupa diastolele lungi (FA, postextrasistolic)
- scade in intensitate - in IVS, chiar si in SA severa
• Examenul cordului
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Caracteristici ale prinicpalelor sufluri
• Stenoza aortica
• Insuf. mitrala• Prolaps mitral • Insuf tricuspida
• Insuf aortica• Stenoza mitrala
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Diferentierea suflului sistolic aortic
• Tineri– suflu functional (inocent)
– Grad I - II– fara alte zgomote– nu se intensifica cu manevra Valsalva– fara HVS
– bicuspidie aortica
• Varsnici– scleroza aortica– stenoza aortica
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Examen fizic
• puls periferic, TA puls periferic, TA
- puls “parvus ef tardus”: incepe tarziu, platou – niciodata
bisferian
- TA > 200mmHg – exclude SA stransa
- remodelarea arteriala la varstnici sterge aceste modificarile pulsului
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ECG
HVS - “sistolic”
HAS - “P- neg V1”
Fals IM ant-septal
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Modificarile radiologice in SAModificarile radiologice in SA
• depind de • varsta pacientului • severitatea SA
– Copii: SA severa •EPA/ICC
– Adult•inima dimensiuni normale•dilatatie aortica poststenotica•vascularizatie pulmonara normala
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Rx: aorta ascendenta cu dilatatie poststenotica
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Rx: aorta ascendenta cu dilatatie poststenotica
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Dilatatia poststenotica de aorta ascendenta
Apare:
- de obicei in SA valvulare
- la orice varsta :
- determinata de
- tulburenta fluxului sanguin
- leziune de jet
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- Dilatatie post stenotica
- VS bombeaza usor
- Calcificari - de buton aortic- sigmoide (profil)
- AS mare - asociere valvulopatie mitrala
Rx grafia pulmonaraRx grafia pulmonara
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Calcificarile valvulare aortice
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Criterii clinice ECG si Rx de SA stransaSemn Corelatie cu
severitateaApex - deplasat, miscare sustinuta
Da
Cardiomegalie (clinc, Rx, Eco) Da
Freamat Nu
Suflu sistolic - intensitate
Nu
-varf tardiv in sistola Da
Zg1 diminuat Da
Zg 3, 4 cu HVS Da
Dedublare paradoxala Zg2 Da
ECG – HAS, HVS Da
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EcocardiografiaEcocardiografia
• Etiologia– Bicuspidia etc..– Coarctatia asociata
• Severitatea SA– Gradientul transvalvular– Aria valvulara Ao
• HVS– disfunctia VS– anomalii de contractie VS
• AS
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Bicuspidie aortica
ETT - 2D
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- morfologia valvei (bicuspa, etc..)- evaluarea tractului de ejectie VS- masurarea suprafetei orificiului aortic
- nu este necesara in SA simptomatica cu gradient transvalvular > 50mmHg
Eco transesofagian
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ETT - 2D
- ingrosare valve, calcificari - reducerea deschiderii valvulare
-dimensiuni cavitati
- HVS – disfunctie diastolica VS - functia sistolica VS
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-gradient mediu
VS/Ao
40mmHg = SA severa
-Doppler pulsat ( camera de ejectie VS)
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Severitatea SASeveritatea SA
• Aria valvulara normalanormala 2,5-3,5cm2
• SA mediemedie 1,5 - 2,5cm2
• SA moderatamoderata 1 – 1,5cm2
• SA severasevera < 1cm2
• SA critica <0.8cm2 ;<0.6 cm2 /m2 BSA– debutul simptomelor
–0,9cm2 fara BCI–0,7cm2 cu BCI
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Complicatii SA Complicatii SA
- EPA
- Endocardita infectioasa
- Aritmii ventriculare – moarte subita
- Tulburari de conducere AV
- AVC embolice
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Tratament medical Tratament medical
Mentinerea RS - conversia la RS a FA
IVS - spironolactona - efecte antifibrotice in HVS
- diuretice ansa cu atentie: risc hipoTa ortostatica
- digoxin in FA cr
Profilaxia endocarditei infectioase - nu mai este recomandata
Atentie : - digoxina: aritmii ventriculare- deshidratarea, vasodilatatoare
( nitroglicerina) si BB pot determina hipo TA
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Indicatii de tratament chirurgical Indicatii de tratament chirurgical - protezare valvulara- protezare valvulara
1.SA severa simptomaticasimptomatica
2.SA severa la pac cu ind. De CABG, chir Ao, corectia altor valvulopatii, FE < 50%
3.SA severa asimptomaticaasimptomatica daca
La TE – devine simptomatica
- se asoc cu hTA
- se asoc cu TR ventriculare
4. SA medie la pac cu ind. De CABG, chir Ao, corectia altor valvulopatii,
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Indicatii de tratament chirurgical Indicatii de tratament chirurgical - TAVI- TAVI
SA severa cu
1.Contraindicatie de protezare valvulara
2. Risc foarte crescut la protezare valvulara
DACA
Speranta de viata > 1 an
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Contraindicatiile protezarii valvulare aortice
Varsta – nu este o contraindicatie1. Aorta potelanata2. Rx terapia anterioara
la nivel toracic 3. Sternotomii anterioare
4. Boala pulmonara severa
(capacitate totala pulmonara <50%)
5. IRC cu Cl creatinina , 30ml/min6. Obezitatea morbida (BMI 50 - rar in Europa)
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Proteze mecanice
• cu bila– Starr-Edwards
• cu disc– “single-tilting”
– Medronic-Hall– Omniscience
– “bileaflet – tilting”– St. Jude
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Proteze biologice
Proteza Hancock - valva porcina
Proteza Carpentier-Edwards - valva din pericard bovin.
Homogrefa -valva aortica de la cadavru
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Protezele valvulare
Mecanice
– durabile– risc mare de
complicatii tromboembolice•terapie cronica cu ACO
Biologice
– nu sunt durabile – se iau in
consideratie mai ales la varstnici
– risc mic de complicatii tromboembolice
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Factori ce determina selectiaproteza mecanica / biologica
1. Proteza biologica
- varsta > 65 ani
- comorbiditate: BCI, BPCO, etc
- femei in periada fertila 2. Proteza mecanica
- varsta tanara
- proteze duble
- nevoia de anticoagulare
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Protezarea valvulara la adult
- risc de deces operator 4% la FE normala
20 – 30 % FE<35% 2 - 5% la < 70 ani
- supravietuirea la 5 ani: 80 – 94% la 10 ani 68- 89%
- factori de risc pentru decesul tardiv :- clasa NYHA perioperator- aritmiile ventriculare perioperatorii- IA concomitanta- Fib atriala- boala coronariana, antecedente de IM- sex F
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Protezele valva aortica- mortalitatea si morbiditate operatorie la varsnici
• Riscul este determinat de comorbiditati
• Varsta nu este o contraindicatie pentru chirurgia valvei aortice– Beneficile la varstnic
• reducerea mortalitatii si morbiditatii• cresterea calitatii vietii
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B. Tratamentul chirurgical in SA la copii
I Valvuloplastie cu balon - complicatii:
- IA, restenoza dupa 10-20 ani II. Operatia Ross
- indicata dupa valvuloplastia anterioara
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Operatia Ross
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SA stransa
DA
Speranta de viata limitata
NU DA
Protezare valvulara chirurgicala
NU
Pacient simptomatic
Contraindicatii sau risc chirurgical inacceptabil
Tratament medical
Protezare valvulara percutanata
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Concluzii
• SA valvulopatie cu incidenta in cerstere
• SA critica poate fi tratata chirurgical/interventional cu riscuri mici