Stenoza tricuspidian

1. 2.

Etiologie
Reumatismal n peste 95% din cazuri Cauze rare: sindrom carcinoid, boala Whipple, mixom atrial drept

Elemente de diagnostic ecocardiografic Criterii M i 2D:

1. 2. 3. 4. 5. ngrori, calcificri valvulare, de inel, fuziuni comisurale Mobilitate redus, doming Curb nalt descris de valv fa de planul inelului Modificri ale aparatului subvalvular: calcificri, retracii, mobilitate redus Elemente nespecifice n modul M Identific jet turbulent diastolic cu zon de convergen pe faa atrial

Doppler color

Criterii doppler
1. 2. 3. 4. Gradientul diastolic transtricuspidian (mediu) Aria valvei tricuspide (metoda PHT) Pt. PHT constanta 220 de la VM se nlocuiete cu 190 AVT (cm) = 190/PHT Criterii pt. ST sever: Gradient mediu de repaus 7 mmHG AVT 1 cm2 PHT > 190 ms
Datorit variaiilor respiratorii ale fluxului din cordul drept, msurtorile se efectueaz postexpirator

Regurgitarea tricuspidian Etiologie

70% dintre
indivizii normali prezint RT minim/uoar, considerat fiziologic

Primar Secundar Reumatismal HTP primitiv Prolaps HTP secundar EI CPcr. B. Ebstein Sindrom carcinoid Sindrom hipereozinofilic

Evaluare ecocardiografic
Seciuni recomandate:
1. 2. 3. 4. PS ax lung la nivelul tractului de intrare n VD PS ax scurt la baza marilor vase Apical 4 cam. Subcostal

2D:
Detectarea etiologiei RT Diferenierea dintre RT primare/secundare prin evidenierea modificrilor morfologice Dilatarea de inel tricuspidian ( 40mm) Date indirecte asupra severitii prin identificarea VD dilatat, raport VD/VS crescut, micare paradoxal SIV, SIV aplatizat.

M color: cronologia fluxului i dinamica lui n timpul sistolei

Evaluare ecocardiografic Doppler color:

Sensibilitate i specificitate foarte bun Principala matod de detectare i de apreciere a severitii RT Identific jet sistolic turbulent n vecintatea valvelor tricuspidiene, care ptrunde n AD Se pot aprecia: 1. Dimensiunile jetului de RT (lungime, arie) 2. Vena contracta (> 7mm RT sever, dimensiunile nu sunt standardizate pt. RT uoar, moderat) 3. PISA 4. Raport arie jet RT/arie AD Seciune de elecie: apical 4 camere, parasternal pt. caviti drepte

Definire RT sever
Criteriu ecografic Arie jet Arie jet/arie AD Vena contracta Aspect anvelopa Doppler Flux venos hepatic Aspect valve tricuspide RT uoar < 5 cm Nu s-a definit Nu s-a definit Densitate sczut,form simetric Dominan sistolic De obicei nl RT sever 10 cm 30% 7mm Densitate crescut, form triunghiular cu vf. Precoce Reflux sistolic Lips cooptare, remaniere De obicei dilatate

Dimensiuni VD, AD,VCI De obicei nl

Doppler spectral
Doppler pulsat metod indirect de apreciere a severitii, un flux
transtricuspidian cu o velocitate cu und E>1m/s = RT sever, dac nu se asociaz cu stenoza

Doppler continuu
Anvelop cu V< 2,5 m/s fiziologic n condiii patologice similar altor regurgitri valvulare velocitatea nu reflect severitatea n RT masive veloc. sczute (<2m/s) = egalizarea rapid a diferenelor de presiune VD/AD RT moderate cu HTP important jet cu velocitate mare RT masive anvelopa doppler are aspect triunghiular sau cu umr telesistolic (egalizarea rapid a diferenelor de presiune VD/AD)

Flux venos hepatic

evaluarea fluxului din vena cav inferioar i venele hepatice n RT sever apare reflux sistolic n venele hepatice Factorii care influeneaz patternul fluxului venos hepatic:
Compliana AD, VD Fazele ciclului respirator Tulburrile de ritm (FiA) Presarcina Refluxul sistolic din VCI i VCS se coreleaz clinic cu pulsaiile jugularelor

Forme etiologice
RT reumatismal
Foarte rar izolat Se asociaz frecvent cu valvulopatia mitral Valve ngroate, remaniate, cordaje scurte

RT din EI
Vegetaii ataate VT, frecvent mari, pe faa atrial Lips de subst. la nivelul cuspelor deficit de coaptare

RT din prolapsul valvelor tricuspidiene

Rar izolat, frecvent asociat cu PVM Valve cu excursii ample Apical 4 cam = incidena de elecie

RT din Boala Ebstein

Indicaii de trat. Chirurgical n RT

Indicaia
Anuloplastie pt RT sever i HTP sever la pacienii cu leziuni valvulare mitrale care necesit corecie chirurgical nlocuire valvular pt RT sever secudar unor anume leziuni ale valvelor tricusp care nu por fi corectate prin anuloplastie nlocuire valvular sau anuloplastie pt RT sever cu PAP medie < 60 mm Hg, simptomatic Anuloplastie pt RT uoar la pacieni cu HTP secundar unor leziuni valvulare mitrale care necesit corecie chirurgical nlocuire valvular sau anuloplastie pt RT cu PAP < 60 mm Hg n prezena unei valve mitrale nl, la pacieni asimptomatici la care nu s-a ncercat tratament diuretic

Clasa
I IIa IIa IIb III

Regurgitarea pulmonar
60 70% dintre nl. Prezint RP minim/uoar, considerat fiziologic Etiologie: HTP Dilatare AP Prolaps (boli esut conjunctiv) Iatrogen (dup valvulotomie pulmonar) Sindrom carcinoid

Doppler color jet diastolic turbulent n TEVD Evaluare eco:

Stabilirea etiologiei Msurarea inelului i tr.AP Morfologia aparatului valvular

Regurgitarea pulmonar
Mod M: Semne indirecte : VD dilatat, raport VD/VS crescut, SIV paradoxal Doppler color Dimensiunile jetului, orientarea, distana pn la care ajunge n VD Lungime < 10 mm = RP uoar Jet central, scurt = RP fiziologic Doppler pulsat: evalueaz prezena Doppler continuu:
Intensitatea semnalului Veloc (calc PAP diast. i medii) Rata de decelerare (RP uoar decelerare lent, RP decelerare rapid).

Hipertensiunea pulmonar

Definiie
PAP sistolic > 35 mm Hg PAP diastolic > 15 mm Hg PAP medie > 25 mm Hg

Modul M
Unda a a VP diminuat/absent nchiderea/incizura mezosistolic a VP Semne indirecte

2D
Dilatarea cavitilor drepte VS de forma literei D datorit aplatizrii SIV

Evaluarea Doppler a HTP

Regurgitarea tricuspidian Regurgitarea pulmonar Timpul de accelerare n tractul de ejecie al VD Fluxul n venele hepatice Funcia VD

HTP Regurgitarea tricuspidian

Velocitatea maxim a jetului de RT = gradient de pres. AD-VD (ecuaia Bernoulli) = VRT Doppler continuu Seciuni: apical 4 cam., ps ax lung modificat ptr.tractul de intrare VD, subcostal, ps ax scurt la baza marilor vase PSVD (pres. Sist VD) = PAPs = P(VD-AD) + PAD = = 4x VRT + PAD (fr SP!) Clinic PAD poate fi evaluat prin gradul de turgescen jugular ECO: PAD este estimat prin VCI n timpul respiraiei:

Diametru VCI
Mic (< 15 mm) Normal (15+25 mm)

Modificarea cu respiraia
colaps Scade cu > 50%

PAD estimat (mmHg)

Normal (15+25 mm)

Dilatat (>25 mm)

Scade cu < 50%

Scade cu < 50%

05 5 10 10 15 15 20 > 20

Dilatat cu VH dilatate

Nu se modific

HTP regurgitarea tricuspidian RT apare la >75% din populaia adult VRT normala 2-2,5m/sec. VRT> 3m/sec HTP sau obstr. n tractul de ejecie VD sau SP n caz de SP: PAPs = (4VRT+PAD) 4VAP n condiii de cretere marcat a PAD (IM de VD, IVD, RT sever) VRT poate fi < 2,5 m/sec, se subestimeaz PAP Dg dif al fluxului RT

HTP
N
PAP sistolic (mmHg) < 30

HTP uoar 30 44

HTP medie 45 70

HTP sever > 70

PAP diast. (mmHg)

40

HTP regurgitarea pulmonar

Permite estimarea PAP medii i diastolice Veloc. jetului de RP de la sfritul diastolei reflect gradientul de presiune dintre AP i VD; P telediast din VD = PAD (cca 10 mmHg): PAP diast.= 4xV(teleRP) + PAD PAPm = 4xV(protoRP)

HTP flux tract de ejecie VD, flux vene hepatice, funcie VD

Faza de acceleraie a fluxului din TEVD scade pe msur ce PAP crete Eantion doppler pulsat plasat central la nivelul inelului pulmonar TAP (intervalul dintre debutul fluxului i Vmax): valori nl 120msec PAPm = 79 0,45xTAP TAP aparent normal (disfuncie sistolic de VD, debit crescut n cavitile drepte). Inversarea fluxului sistolic la nivelul venelor hepatice datorit presiunilor telediastolice crescute i scderii complianei VD.

FIGURE 772. Pulsed-wave Doppler in the right ventricular outflow tract demonstrating varying degrees of pulmonary artery systolic pressure. A, Record of a normal individual. Note the normal acceleration time, defined as the time in milliseconds from onset of ejection to reaching peak velocity. In this instance the acceleration time is approximately 200 milliseconds. B, Record in a patient with modest pulmonary hypertension. Note the shortened acceleration. C, Record in a patient with severe pulmonary hypertension. Note the remarkably short acceleration time as well as the systolic notching in the flow pattern.

W.B. Saunders Company items and derived items copyright 2001 by W.B Saunders Company.

PVT

CD Figure 855. Tricuspid valve prolapse (TVP) is present in 0.1 to 5.5 percent of the general population and in about 22 percent of patients with mitral valve prolapse. Tricuspid regurgitation (TR) is usually mild and does not correlate with the severity of the prolapse. TVP usually involves the septal leaflet (SL) alone or both the SL and the anterior leaflet (AL). Note redundancy of AL and SL; the posterior leaflet (PL) is normal. RA = right atrium.

W.B. Saunders Company items and derived items copyright 2001 by W.B Saunders Company.

CD Figure 859. Severe right ventricular (RV) volume overload due to tricuspid regurgitation resulted in the severe RV dilation seen in this parasternal short-axis echocardiogram. The septum (arrows) is slightly flattened at end-diastole. LV = left ventricle.

W.B. Saunders Company items and derived items copyright 2001 by W.B Saunders Company.

FIGURE 769. Right ventricular inflow tract view recorded in a patient with carcinoid disease and tricuspid regurgitation. The right atrium and right ventricle are both visualized in this systolic frame. The tricuspid valve leaflets are abnormally dense and immobile. In this systolic frame the leaflets fail to coapt with the leaflet tip separated by approximately 2 cm. In real time the leaflets are nearly immobile.

W.B. Saunders Company items and derived items copyright 2001 by W.B Saunders Company.

FIGURE 768. Two-dimensional echocardiograms with color flow imaging of patients with tricuspid regurgitation. Top, Echocardiogram is recorded in a patient with a mild degree of tricuspid insufficiency. Bottom, Echocardiogram of a patient with severe tricuspid regurgitation.

W.B. Saunders Company items and derived items copyright 2001 by W.B Saunders Company.