INSUFICIENTA MITRALA

Anatomia normala a valvei mitrale

Morris M F et al. Radiographics 2010;30:1603-1620

Anatomia normala a valvei mitrale
valve si comisuri
Anatomia normala a valvei mitrale
Zona de coaptare
Anatomia normala a valvei mitrale
Inelul mitral
Anatomia normala a valvei mitrale
cordaje
Anatomia normala a valvei mitrale
muschi papilari
 MANIFESTARI CLINICE
ANAMNEZA

n  interval liber de cateva decade

n  simptomele apar cand se produce decompensarea VS:
n  Dispnee de efort → EPA, ortopnee, DPN
n  Oboseala
n  tuse
n  Fatigabilitate

n  Mai rar decat in stenoza mitrala:

n  Hemoptizii
n  Embolii sistemice (FiA)

n  Angina pectorala – in boala coronariana coexistenta

 EXAMEN FIZIC
PALPARE

n  soc apexian deplasat la stanga si inferior

n  dublu impuls apexian ± freamat sistolic la apex

 EXAMEN FIZIC

AUSCULTATIE
n  Z 1 diminuat
n  Z 2 dedublat (scade perioada de ejectie VS)
n  Z 3 prezent ( ≠ de IVS)
n  Suflu sistolic:
n  holosistolic – imediat dupa Z 1, continua dupa Z 2

n  protosistolic – in IM acuta (creste rapid presiunea in AS)

n  mezotelesistolic

n  prolaps de valva mitrala

Caracterele suflului de insuficienta mitrala
Ø  maxim la apex, iradiere in axila
(poate iradia si catre baza – jet excentric sub VMP)

Ø  se modifica putin cu volumul bataie

Ø  ! IM silentioasa

Ø  uruitura diastolica (debit diastolic crescut prin VM)

Ø  suflul
sistolic - ↓ de ortostatism si Valsalva, ↑ de
exercitii izometrice
Diagnosticul diferential al suflului de IM
n  Stenoza aortica
n  suflu de ejectie
n  maxim in focarul aortic → iradiere pe vasele mari
n  variabil cu volumul bataie
n  Insuficienta tricuspidiana
n  pe marginea stanga a sternului
n  se accentueaza in inspir
n  jugulare turgescente si pulsatile
n  Defectul septal interventricular
n  maxim parasternal
n  copii
n  Cardiomiopatia hipertrofica obstructiva
n  se accentueaza in ortostatism, Valsalva
 BOALA MITRALA

n  Predominant IM n  Predominant SM

n  Z1 diminuat n  Z1 accentuat

n  Prezenta Z 3 n  Clacment de

n  Dublu impuls la deschidere a

apex mitralei (CDM)
n  Suflu sistolic scurt
 PARTICULARITATI CLINICE IN
INSUFICIENTA MITRALA ACUTA
n  CAUZE:
n  Endocardita infectioasa
n  Ruptura m. papilar/cordaj
n  Disfunctie de proteza mitrala

n  CLINIC:
n  Edem pulmonar acut
n  Suflu descrescator/holosistolic
n  Galop protodiastolic
n  Semne de HTP si decompensare dreapta
n  TA scazuta → soc + congestie pulmonara, FC
↑
 INVESTIGATII DE LABORATOR
n  ECG → anomalie de AS
→ fibrilatie atriala
→ hipertrofie VS → 1/3 din cei cu IM severa
→ hipertrofie VD → 15%

n  Radiografie CP - cardiomegalie (AS, VS)

- edem interstitial (IVS)

> SM – cardiomegalie usoara, modif. pulmonare ↑

> IM – cord mare, modificari pulmonare ↓, AS
dilatat anevrismal (adesea > decat in stenoza
mitrala)
 ECOCARDIOGRAFIA TRANSTORACICA
n  INDICATII ACC/AHA:
n  Evaluarea initiala a - severitatii IM I
- functiei VS I
n  Determinarea mecanismului I
n  IM severa asimptomatica, la 6 – 12 luni, pt functia VS I
n  Status cardiac dupa o modificare a simptomelor I
n  Evaluare postoperatorie I

n  Evaluarea de rutina a IM usoare cu functie si

dimensiuni normale VS III
 ECOCARDIOGRAFIA TRANSTORACICA
n  2D:
n  Cavitati stangi dilatate
n  Posibile etiologii:
n  Cordaj rupt
n  Prolaps VM

n  Vegetatii

n  Calcificari/dilatare inel

n  Consecinte
hemodinamice → prognostic
preoperator:
n  Bun:FE > 60%, DTSVS < 45 mm
n  Nefavorabil: FE < 50%, DTSVS > 50 mm
Insuficienta mitrala - etiologie

Reumatismala
Ischemica
CMD idiopatica
 TEE

Endocardita
Cleft valva mitrala
 Particularitati de evaluare in
insuficienta mitrala acuta
n  RX - cord de dimensiuni normale sau usor crescute
- hipertensiune pulmonara venocapilara
n  TTE :
n  AS si VS de dimensiuni normale
n  Hiperkinezie VS

n  TEE:
n  Cauza anatomica a IM
n  Severitatea regurgitarii
n  ± Ghidarea interventiei reparatorii
 ALTE INVESTIGATII

n  Cateterism:
INDICATII ACC/AHA
§  Discrepante intre clinica si investigatiile neinvazive I

§  Testele neinvazive sunt neconcludente I

§  Nu se are in vedere interventia chirurgicala III

 ALTE INVESTIGATII
Coronarografie:
n 

INDICATII ACC/AHA
§  Interventie chirurgicala la pacienti cu:
§  Angina pectorala/ infarct miocardic I
§  ≥ 1 FR pentru boala coronariana I
§  Cand se suspecteaza etiologia ischemica I
§  Pentru a confirma testele neinvazive la pac. nesuspectati de
boala coronariana II b
§  Interv. chrg. la pac. < 35 ani, fara suspiciune clinica de
boala coronariana III
 DIAGNOSTIC DIFERENTIAL

n  Al etiologiei insuficientei mitrale

n  Al suflului sistolic
n  Insuficientatricuspidiana
n  Stenoza aortica

n  Cardiomiopatia hipertrofica – HVS + unde T -

ample ± unde Q
n  Defectul septal ventricular
 ISTORIA NATURALA
n  Depinde de
n  etiologie
n  severitate - IM usoara/moderata – evolueaza multi ani
asimptomatic
- IM severa simptomatica – mortalitate 5% /an
n  debutul (acut/treptat)

n  starea miocardului VS

n  afectiuni asociate – valvulare, nevalvulare

n  Influentata decisiv de tratamentul chirurgical

n  IM severa cu tratament medical – suprav. la 5 ani – 45%
n  Schoen F J,
St John
Sutton M;
Hum Pathol
18:568,1987
 COMPLICATII
n  Endocardita infectioasa - deteriorare neasteptata a
starii clinice

n  Edem pulmonar acut - ! Efort fizic exagerat, ritm

rapid (ex: FiA), anemie, hipertiroidie, febra

n  Embolii sistemice - mai rare decat in stenoza

mitrala

n  Fibrilatia atriala - greu de convertit, predictor

independent al supravietuirii postoperatorii

n  Deteriorarea functiei VS - insuficienta cardiaca

 TRATAMENT MEDICAL

n  REDUCEREA POSTSARCINII VS –

beneficiu particular :

n  ↓ impedanta la ejectia in aorta → ↓ volumul

regurgitant
n  ↓ dimensiunilor VS → ↓ aria orificiului
regurgitant
 TRATAMENT MEDICAL

n  IM ACUTA
n  nitroprusiat de sodiu iv la pacientii normotensivi

n  nitroprusiat
de sodiu iv + inotrop pozitiv
(dobutamina) la pacientii hipotensivi

n  Balon intraaortic de contrapulsatie – pentru

stabilizarea preoperatorie

n  +tratament antibiotic adecvat in endocardita

infectioasa
 TRATAMENT MEDICAL
n  IM CRONICA
- ASIMPTOMATICI
n  nu exista tratament medical acceptat in mod
general
n  Pare logica administrarea vasodilatatoarelor
dar…
n  Nu exista studii
n  In absenta HTA – nu exista indicatii dovedite ale
vasodilatatoarelor la pac. asimptomatici cu functie
VS pastrata
 TRATAMENT MEDICAL

n  IM CRONICA SEVERA cu contraindicatii de trat

chirurgical:
n  Trat insuficientei cardiace si/sau al complicatiilor
 TRATAMENT CHIRURGICAL

n  Insuficienta mitrala acuta (simptomatica)

n  Insuficienta mitrala cronica severa

n  Simptomatica

n  Asimptomatica + disfunctie VS

 TRATAMENT CHIRURGICAL

TIPURI DE INTERVENTIE CHIRURGICALA

n  repararea / reconstructia valvei mitrale

n  inlocuirea valvulara cu pastrarea aparatului mitral

(partial/total)

n  inlocuirea valvulara cu indepartarea aparatului

mitral
 REPARAREA VALVEI MITRALE
n  AVANTAJE:
n  prezervarea valvei native
n  evitarea riscurilor asociate protezarii valvulare
n  mortalitate operatorie mica, 2 -3% (fata de 5-6 %
pentru inlocuirea valvulara)
n  mentinerea integritatii aparatului mitral –
functie VS si supravietuire mai bune
postoperator
! Aparatul mitral este parte integranta din VS,
esentiala pentru mentinerea formei, volumului si
functiei normale
 REPARAREA VALVEI MITRALE
n  DEZAVANTAJE
n  necesita o tehnica chirurgicala mai performanta, experienta
n  manevra mai laborioasa – CEC dureaza mai mult

n  poate eşua!

n  Poate sa apara obstructie in tractul de golire VS ( 5 – 10 % )

– prin miscare anterioara sistolica a VMA –
n  betablocante, incarcare volemica, uneori reinterventie

ESTE TEHNICA CHIRURGICALA DE ELECTIE CAND

ANATOMIA VALVEI ESTE POTRIVITA SI ECHIPA
CHIRURGICALA EXPERIMENTATA
 TRATAMENT CHIRURGICAL –
MOMENTUL OPTIM?

n  Pacienti asimptomatici cu functie VS normala (FE

>60%, DTSVS < 45 mm) – nu se recomanda
tratament chirurgical “profilactic”
n  Exceptii:
n  Fibrilatia atriala episodica/cronica recenta la pacienti cu
sanse mari de reusita a unei interventii de reparare valvulara

n  Hipertensiunea pulmonara (PAPS > 50 mm Hg in repaus,

> 60 mm Hg la efort)
 TRATAMENT CHIRURGICAL

n  Pacientii simptomatici (simptome de IC) cu

functie VS normala necesita tratament
chirurgical. ( clasa I )

n  Se
prefera repararea valvulara sau inlocuirea
valvei cu pastrarea aparatului subvalvular
 Symptoms

Tratamentul in No

regurgitarea mitrala LVEF 60% or

LVESD 45 mm
Yes

organica cronica severa LVEF >30%

Yes No

No Yes
Refractory to
medical therapy

New onset of AF or
SPAP >50mmHg

Yes No

No Yes
Durable valve
repair is likely
and low
comorbidity
High likelihood of
durable repair, low
surgical risk, and
presence of risk
factorsa
Yes No

No Yes

Guidelines on the management of

Surgery Extended HF Medical
valvular heart disease. Eur Heart J 2012. Follow-up (repair whenever possible) treatmentb therapy

AF = atrial fibrillation; BSA = body surface area; HF = heart failure; FU = follow-up; LA = left atrium; LV = left ventricle; LVEF = left ventricular ejection fraction;
Guidelines on the management of valvular heart
disease (version 2012)
The Joint Task Force on the Management of Valvular Heart Disease
of the European Society of Cardiology (ESC) and the European
Association for Cardio-Thoracic Surgery (EACTS)
Authors/Task Force Members: Alec Vahanian (Chairperson) (France)*, Ottavio Alfieri
(Chairperson)* (Italy), Felicita Andreotti (Italy), Manuel J. Antunes (Portugal),
Gonzalo Barón-Esquivias (Spain), Helmut Baumgartner (Germany),
Michael Andrew Borger (Germany), Thierry P. Carrel (Switzerland), Michele De Bonis
(Italy), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Bernard Iung
(France), Patrizio Lancellotti (Belgium), Luc Pierard (Belgium), Susanna Price (UK),
Hans-Joachim Schäfers (Germany), Gerhard Schuler (Germany), Janina Stepinska
(Poland), Karl Swedberg (Sweden), Johanna Takkenberg (The Netherlands),
Ulrich Otto Von Oppell (UK), Stephan Windecker (Switzerland), Jose Luis Zamorano
(Spain), Marian Zembala (Poland)
ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (Chairperson) (The Netherlands), Helmut Baumgartner
(Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium),
Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands), Paulus Kirchhof
(United Kingdom), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France),
Bogdan A. Popescu (Romania), Željko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway),
Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland)

Document Reviewers:: Bogdan A. Popescu (ESC CPG Review Coordinator) (Romania), Ludwig Von Segesser (EACTS
Review Coordinator) (Switzerland), Luigi P. Badano (Italy), Matjaž Bunc (Slovenia), Marc J. Claeys (Belgium),
Niksa Drinkovic (Croatia), Gerasimos Filippatos (Greece), Gilbert Habib (France), A. Pieter Kappetein (The Netherlands),
Roland Kassab (Lebanon), Gregory Y.H. Lip (UK), Neil Moat (UK), Georg Nickenig (Germany), Catherine M. Otto (USA),
John Pepper, (UK), Nicolo Piazza (Germany), Petronella G. Pieper (The Netherlands), Raphael Rosenhek (Austria),
Naltin Shuka (Albania), Ehud Schwammenthal (Israel), Juerg Schwitter (Switzerland), Pilar Tornos Mas (Spain),
Pedro T. Trindade (Switzerland), Thomas Walther (Germany)
The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines
Online publish-ahead-of-print 24 August 2012