stenoza tricuspidiana
TRANSCRIPT
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STENOZA STENOZA TRICUSPIDIANĂTRICUSPIDIANĂ
STENOZA STENOZA TRICUSPIDIANĂTRICUSPIDIANĂ
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DefiniţieDefiniţie
obstrucobstrucţţia fluxului sanguin ia fluxului sanguin transtricuspidian transtricuspidian îîn cursul umplerii n cursul umplerii diastolice a diastolice a VDVD, cu instalarea unui , cu instalarea unui gradient presional transvalvular gradient presional transvalvular diastolicdiastolic
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EtiologieEtiologie
1.1. RAARAA2.2. AtreAtrezzie congenitalie congenitală de valvă tricuspidăă de valvă tricuspidă3.3. Sindrom Sindrom carcinoicarcinoidd4.4. Tumori AD Tumori AD 5.5. Fibroza endomiocardicFibroza endomiocardică ă 6.6. Vegetaţii VTVegetaţii VT7.7. Lupusul eritematos sistemicLupusul eritematos sistemic
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FiziopatologieFiziopatologie
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Tablou clinicTablou clinic
debit cardiac debit cardiac : : astenie, fatigabilitate astenie, fatigabilitate
discomfort abdominal discomfort abdominal şşi anorexie i anorexie secundaresecundare congestiei viscerale, congestiei viscerale, hepatomegaliei de stazhepatomegaliei de stazăă şşi revi revăărsatului rsatului peritonealperitoneal
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Examen obiectivExamen obiectiv
edeme refractareedeme refractare aascitscităă hepatomegalie de stazhepatomegalie de stază +ă + ciroz cirozăă + + icter icter vvene jugulare turgescenteene jugulare turgescente ccaaşşexieexie
AscultaAscultaţţia corduluiia cordului :: uruitura diastolicăuruitura diastolică (semnul Carvalo)(semnul Carvalo) CDTCDT
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Examene paracliniceExamene paraclinice
1. ECG2. Rx toracică3. Ecocardiografie4. Cateterism cardiac
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Examene paracliniceExamene paracliniceRx toracică
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EcocardiografieEcocardiografie
Diagnostic de severitate
ST uşoară medie severă
Vmed (m/s2) < 1 1 – 1,2 > 1,2
Pmed (mmHg) < 3 3 – 5 > 5
S (cm2) > 3 3 – 1,8 < 1,7
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Diagnostic pozitivDiagnostic pozitiv
Examen obiectiv
+
Investigaţii paraclinice
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TratamentTratament
A.Tratament medicamentosB.Tratament chirurgicalC.Profilaxia EI
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TratamentTratament
C. Tratament chirurgical
- Indicaţii: gradient presional diastolic transtricuspidian > 4-5 mm Hg
- metode: protezarea cu valvă biologică !
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INSUFICIENŢAINSUFICIENŢATRICUSPIDIANĂTRICUSPIDIANĂINSUFICIENŢAINSUFICIENŢA
TRICUSPIDIANĂTRICUSPIDIANĂ
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DefiniţieDefiniţie
prezenprezenţţa unui flux sanguin sistolic a unui flux sanguin sistolic retrograd din retrograd din VDVD îîn n ADAD, ca urmare a , ca urmare a incompetenincompetenţţei aparatului valvular ei aparatului valvular tricuspidiantricuspidian
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EtiologieEtiologie
FuncţionalăCauze rare:
EI (utilizatorii de narcotice pe cale i.v.), prolapsul valvular tricuspidian, RAA, disfuncţia ischemică sau ruptura pilierilor în cadrul infarctului miocardic, traumatismele toracice cu ruptura structurilor valvulare, malformaţii congenitale (boala Ebstein, defectul septal atrial), carcinoidul malign, boli ale tesutului conjunctiv.
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FiziopatologieFiziopatologie
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Examen obiectivExamen obiectiv
semne de congestie venoassemne de congestie venoasăă sistemicsistemică:ă: - - vene jugulare turgescente, vene jugulare turgescente,
- - hepatomegalie de stazhepatomegalie de stazăă, , - - reflux hepatojugular pozitiv reflux hepatojugular pozitiv - - pulsapulsaţţii sistolice ale ficatului, ii sistolice ale ficatului, - - edeme declive masive edeme declive masive - - ascitascităă; ;
fibrilafibrilaţţia atrialia atrialăă
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Examen obiectivExamen obiectiv
AscultaAscultaţţia corduluiia cordului::
suflul holosistolic de suflul holosistolic de RTRT(( suflul amplificat suflul amplificat înîn inspir inspir = = semnul Carvallo).semnul Carvallo).
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Examene paracliniceExamene paraclinice
1. ECG2. Rx toracică3. Ecocardiografie4. Cateterism cardiac
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Examene paracliniceExamene paracliniceRx toracică
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EcocardiografieEcocardiografie
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Diagnostic pozitivDiagnostic pozitiv
Examen obiectiv
+
Investigaţii paraclinice
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TratamentTratament
A. Tratament medicamentosB. Tratament chirurgicalC. Profilaxia EI
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VALVULOPATII VALVULOPATII PULMONAREPULMONARE
VALVULOPATII VALVULOPATII PULMONAREPULMONARE
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Stenoza pulmonarăStenoza pulmonarăStenoza pulmonarăStenoza pulmonară
- - congenitalăcongenitală
- reumatismală – extrem de rar; tabloul clinic - reumatismală – extrem de rar; tabloul clinic al celorlalte valvulopatii reumatismale al celorlalte valvulopatii reumatismale asociateasociate
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Examene paracliniceExamene paracliniceRx toracică
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EcocardiografieEcocardiografie
SP – eco 2D parasternal ax scurt
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EcocardiografieEcocardiografie
SP – eco 2D parasternal ax scurt
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TratamentTratament
A. Tratament medicamentosB. Valvuloplastie percutană C.Tratament chirurgicalD. Profilaxia EI
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Insuficienţa pulmonarăInsuficienţa pulmonarăInsuficienţa pulmonarăInsuficienţa pulmonară
- - funcţionalăfuncţională
- tablou clinic dominat de afecţiunea primară- tablou clinic dominat de afecţiunea primară
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Examene paracliniceExamene paraclinice
1. ECG2. Rx toracică3. Ecocardiografie4. Cateterism cardiac
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Diagnostic pozitivDiagnostic pozitiv
Examen obiectiv
+
Investigaţii paraclinice
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TratamentTratament
Tratamentul afecţiunii primare
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???
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PROTEZE PROTEZE VALVULAREVALVULARE
PROTEZE PROTEZE VALVULAREVALVULARE
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PROTEZE VALVULAREPROTEZE VALVULARE
MecaniceMecanice
BiologiceBiologice
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ccu bilu bilăă monodisc monodisc cu 2 cu 2 discuridiscuri
PROPROTEZETEZE MECANIC MECANICEE
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Avantaje:Avantaje:
- durată lungă- durată lungă
PROPROTEZETEZE MECANIC MECANICEE
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DezavantajeDezavantaje::
anticoagulare anticoagulare
permanentă permanentă
eficientă eficientă
PROPROTEZETEZE MECANIC MECANICEE
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Indicaţii:Indicaţii:
- pacienţi pacienţi << 65 – 70 ani 65 – 70 ani- pacienţi care necesită pacienţi care necesită
tratament anticoagulanttratament anticoagulant- pacienţi cu insuficienţă pacienţi cu insuficienţă
renală cronicărenală cronică
PROPROTEZETEZE MECANIC MECANICEE
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PROPROTEZETEZE BIOLOGBIOLOGICICEE
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ClasificareClasificare
AutograftAutograft Autolog (autogen)Autolog (autogen) Homograft (alograft)Homograft (alograft) Heterograft (xenograft)Heterograft (xenograft)
Operaţia Ross: Valvă pulmonară → poziţie aortică
Valvă de porcValvă din pericard bovin, etc.
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Heterograft Heterograft (xenograft)(xenograft)
Valvă de porc - Hancock I şi II- Carpentier-Edwards- Intact
Valvă din pericard bovin- Carpentier-Edwards - Ionescu-Shiley
Valvă de porc fără stenturi- Toronto SPV - Freestyle
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Avantaje:
-hemodinamică apropiată de cea normală-Nu anticoagulare
PROPROTEZETEZE BIOLOGBIOLOGICICEE
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Dezavantaje:
-degenerează (durată medie 6-7 ani)
PROPROTEZETEZE BIOLOGBIOLOGICICEE
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Indicaţii:
- vârstnici- femei tinere ce doresc sarcină- contraindicaţii de tratament anticoagulant- necomplianţă la tratament anticoagulant- protezarea valvei tricuspide
PROPROTEZETEZE BIOLOGBIOLOGICICEE
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PROPROTEZETEZE - MOD DE FUNCŢIONARE- MOD DE FUNCŢIONARE
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PROPROTEZETEZE - ANTICOAGULARE- ANTICOAGULARE
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Warfarină
INR 2-3
Warfarină
INR 2,5 – 3,5
Aspirină
50 – 100 mg
Primele 3 luni după inserţia protezei
+ +După primele 3 luni
Valvă aortică + +Valvă aortică + risc + +Valvă mitrală + +Valvă mitrală + risc + +
PROTEZE MECANICE - ANTICOAGULAREPROTEZE MECANICE - ANTICOAGULARE
După ghidul ACC/AHA - 1998
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Warfarină
INR 2-3
Warfarină
INR 2,5 – 3,5
Aspirină
50 – 100 mg
Primele 3 luni după inserţia protezei
+ +După primele 3 luni
Valvă aortică +Valvă aortică + risc +Valvă mitrală +Valvă mitrală + risc + +
După ghidul ACC/AHA - 1998
PROTEZE BIOLOGICE - ANTICOAGULAREPROTEZE BIOLOGICE - ANTICOAGULARE
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I. I. Disfuncţii hemodinamice: Disfuncţii hemodinamice:A.A. Proteze mecanice:Proteze mecanice:
1. “Mismatch”1. “Mismatch”2. Tromboza de protez2. Tromboza de protezăă3. Leak-uri paravalvulare3. Leak-uri paravalvulare4. Alte complica4. Alte complicaţţiiii
B. B. Proteze biologice:Proteze biologice:degenerescenţă în timp degenerescenţă în timp stenoză / stenoză / insuficienţăinsuficienţă
DISFUNCŢII DE DISFUNCŢII DE PROPROTEZĂTEZĂ
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II. TrombembolismII. Trombembolism
III. Hemoragii majoreIII. Hemoragii majore
IV. EndocarditaIV. Endocardita
V. Anemia hemoliticăV. Anemia hemolitică
DISFUNCŢII DE DISFUNCŢII DE PROPROTEZĂTEZĂ
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Tromboza de protezTromboza de protezăă
DISFUNCŢII DE DISFUNCŢII DE PROPROTEZĂTEZĂ
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Leak-uri paravalvulareLeak-uri paravalvulare
DISFUNCŢII DE DISFUNCŢII DE PROPROTEZĂTEZĂ