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Stenoza aortica

Stenoza aortica

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Published by Leonard D
Stagiul de Cardiologie
Spitalul de Urgenta Floreasca
2008/2009
Stagiul de Cardiologie
Spitalul de Urgenta Floreasca
2008/2009

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Published by: Leonard D on Jun 06, 2009
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11/06/2013

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Valva aortica normala

Valva cu trei cuspe si trei comisuri Insertie pe un inel fibros Suprafata VAo normale: N=2.6-3.6
cm2

 

Sinusuri Valsalva: spatiul intre portiunea aortica a cuspelor si perete aortic:
  

Sinus CS Sinus CD Sinus non-coronar

Relatie de vecinatate cu:

Relatia VAo cu coronarele
VD IVA TC

Pu
CD

Ao Tri

CD Cx IVA Cx TC

Mi

Ao

AAS AS

Stenoza aortica (SAo)

Definitie. Valvulopatie caracterizata prin:
 

Obstructia la ejectie a VS cu Aparitia unui gradient de presiune ventriculo- aortic

Leziuni hemodinamice ale:
  

Valvei Ao Tract de ejectie al VS Ao suprasigmoidiana

Incidenta:
 

25% din valvulopatiile cronice 80% din SAo asimptomatice sunt M (M/F = 2-4/1)

↑ cu varsta: de 5 x mai frecventa > 60 ani,

Etiologie
SAo valvulara:

Congenitala:
  

Unicuspidia Bicuspidia Tricuspidia RAA: incidenta in ↓ Calcificata idiopatica Aterosclerotica

Dobandita:
  

-

< 30 ani = SAo congenitala 30-70 ani = RAA, bicuspidie > 70 ani = SAo degenerativa

Unicuspidi a aortica

Cuspa unica; orificiu central sau excentric

Bicuspidie aortica
cea mai frecventa cardiopatie congenitala

Tot bicuspidie …

SAo RAA

SAo “degenerativa”

“Scleroza valvulara Ao”: ingrosarea cuspelor fara gradient
• 25% din cei > 65 ani; • Mai ales la: sex F, HTA, DZ, fumatori, dislipidemici • risc crescut cu 50% de IMA si de deces

C / AHA Guidelines for Management of Valvular Heart Disease. Circulation 2006; 114:e84 – e231.

Calcified nodules in vivo and in vitro. A, Calcific aortic stenosis (horizontal image dimension 4 cm; image kindly provided by Dr Michael Fishbein, UCLA Pathology). B, Dilutionally cloned vascular smooth muscle cells (horizontal dimension 1 cm). The nodules correspond in shape, size, and content.

Demer LL, Tintut Y. Circulation 2008;117;2938-48.

?

Fiziopatologie
1)

Gradientul transvalvular:

Depinde de deschiderea valvei si de functia VS

Disfunctia sistolica a VS scade gradientul VS-Ao > 1.5 cm2 = SAo larga = gradient mediu < 25 mm Hg 1.0 – 1.5 cm2 = SAo medie = gradient mediu 25 – 40 mm Hg < 1 cm2 (0.5 cm2 / m2) = SAo stransa = gradient mediu > 40 mmHg sau gradient maxim > 70 mmHg

Suprafata valvei Ao:
  

2)

Functia sistolica a VS
 

DC se mentine prin ↑ fortei contractile a VS ↑ pres. intracavitara = ↑ intraparietale = HVS concentrica

LEGEA LAPLACE: P intraparietala = P intracavitara x R / grosimea peretelui

 

Sarcomere in paralel; ↑ φ miocitelor DC normal in repaus; creste la efort numai prin tahicardie

C / AHA Guidelines for Management of Valvular HD. Circulation 2006; 114:e84 – e231.

Fiziopatologie
1)

Functia diastolica: prima afectata
  

↓ complianta VS (HVS + fibroza interstitiala) ↓ relaxarea VS (ischemie) Umplerea se face cu presiuni ↑ = ↑ presiunii in AS si capilarul pulmonar

2)

Ischemia miocardica
 

Flux coronarian in repaus ↑ (N fata de masa VS) Mecanisme:
     

HVS si ↓ densitatii capilare ↑ presiunii intracavitare si intraparietale ↑ timpului de ejectie Compresia coronarelor intramurale AS coronara Predominant subendocardica = angina, aritmii, MSC

Anomalii de coagulare: disfunctie plachetara si ↓ F. von Willebrand
  

In SAo severa Echimoze, epistaxis la 20% din pts Dispare dupa inlocuire valvulara

C / AHA Guidelines for Management of Valvular HD. Circulation 2006; 114:e84 – e231.

Manifestari clinice
Simptome:
    

Asimptomatici pana la gradient > 50 mmHg DISPNEE de EFORT: 75% din pts. HVS severa +/- IVS ANGINA: 70% din pts; 50% din cei > 40 ani au AS coronara SINCOPA: SAo stransa; prin hipo-TA sau aritmii V MSC: 15% din SAo cu MSC anterior asimptomatici TA = N (TAs > 200 mmHg exclude SAo stransa) “pulsus parvus et tardus” Soc apexian hiperdinamic Freamat sistolic + tril pe vase mari Clic sistolic focar aortic Z II dedublat paradoxal galop

Semne
      

SUFLU de EJECTIE

Explorari paraclinice: EKG

HVS cu “G” alterat

 

BRS Aritmii:
FA = 10% din pts  ESV si TV nesustinuta la Holter

Explorari paraclinice: Rx

Opacitate cardiaca normala in HVS concentrica

  

Dilatatie Ao post-stenotica Calcificari valvulare Dilatatie VS si semne pulmonare de ICS

Explorari paraclinice:

ECO

Eco normala

ECO:
morfologia valvei Ao: anomalii congenitale

Bicuspidie Ao

ECO:
morfologia valvei Ao: anomalii congenitale

Unicuspidie Ao

Stenoza aortica degenerativa: ecografie 2D

• Calcificarile valvei Ao • Deschidere limitata a cuspelor • HVS concentrica; diametrele VS

Severitatea SAo: ex Doppler
• Calcularea DC • Functia diastolica a VS

• CALCULAREA GRADIENTULU transvalvular aortic

Severitatea SAo: planimetria

Cateterismul stang si coronarografia
  

Masurarea gradientului Ventriculografie = FE Coronarografie: obligatorie dupa 40 ani

Aprecierea severitatii valvulopatiilor asociate

Explorari paraclinice: RMN

“Oldies, but goldies …”

Fonocardiograma

Clic de ejectie, dedublare Z II, suflu sistolic, galop Timpii sistolici

Carotidograma

Anacrota cu panta lenta: timp de semiascensiune > 60 msec = SAo stransa

Incizura dicrota adanca

Timpii sistolici (ECG + fono + carotidograma)

PEP (↓)= Q-Z II -- per. de ejectie (↑)

Dg. pozitiv si diferential
 SAo

= * suflu de ejectie in focar aortic * HVS (ECG, eco) * gradient transvalvular la eco * +/- confirmarea gradientului la cateterism  Dg. diferential:
 CMHO  Insuficienta  DSA  Stenoza

mitrala

pulmonara  Ateromatoza valvei aortice

1. 2. 3. 4. 5. 6. 7. 8.

Aparitia simptomelor

Criterii de severitate ale SAo

Pulsus parvus et tardus; TA sistolica < 130 mmHg Dedublarea paradoxala a Z II Galop stang HVS PE > 0.42 sec T. de semiascensiune sistolica > 0.06 sec Criterii eco:
   

PP > 15 mm, HVS concentrica Deschiderea protosistolica a valvei Ao < 8 mm Gradient transvalvular maxim > 70 mmHg Suprafata Ao < 0.75 cm2 sau 0.5 cm2/m2

9.

ABSOLUT: gradient transvalvular maxim la cateterism > 70

Criteriile de severitate ale SAo

+ G max > 70 mmHg

C / AHA Guidelines for Management of Valvular HD. Circulation 2006; 114:e84 – e231.

Evolutie, complicatii
80% din SAo simptomatice neoperate: exit in 4 ani Progresia SAo medii:

↓ suprafetei cu 0.1 cm2 / an; ↑ gradientului cu 7 mmHg / an Dispnee prin IVS: 1.5 – 2 ani Sincopa: 3 ani Angina pectorala = 3 – 5 ani

Prognostic in functie de simptome:
  

MS aritmica la 10-20% di SAo COMPLICATII:
     

IVS, ICC: cauza de deces Endocardita infectioasa Embolii sistemice BAV si/sau BR IMA: embolic sau tromboza coronariana Aritmii V severe (TV si FV) = MSC

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