Capitolul 32

ECOGRAFIATRANSPLANTULU I CARDIAC

D, Rd.lulesca, D. Z.lrenghes

i\vnnd h vcderc larga rispandire a trunspl. tulur car- i n pri nci prl cx.rni i nrrcaccocardi ograncn nu di fc| l cu
dir c 1 r o ra f lc luali.r ilpind i re l i rn i tl l i c x c l u s i !d c n u n l i rt ul ni nri cdc cxami nrrcticoocardrogral iobi ci tnui tia subi cc{ i lor
don o ri l o rd is ponibili.c c ocrrd i o g ra l inad n s fh n tu l u i c rftl i rc snnnl ofisru ct| {l cc(i uni errdrov.l soul nre. pafti cul l fi i nl ilc
rcp rc,ri n ta un oapilolinr po rta ntit b i n e i n d i !i d u a l r/d rl t c c o- cxrnrnl fi i dcri vtrndcl i n pfl ti eul ari l i l i l esubi ecti l orstnLr) i
r{rd i o g n rl lc i.
\r IrJ I r \ ( J ( i( f . l : r l.,rr n ' J .Irr .l n n " r ' ( (r,r' r' r .L Roferitor la eramin, rea donorilor potcntiAli trcburc sr'l
lftIrsplanLulcirrdirc sc rplica h Lur1ru1r1ilt ej{trenldc rcdus s!bl i ni cmcI rccrl i sunLrcpl c.,cn l anli l i c de !i cl i nrcl cunor
dc holn vi nu vo plczcDr.rccocrfdiogmfir inrnsplrntuluiirl traurrrrnsnrc fi nr pri rrul rl i ndrl c aeci dcnl cl of de ci rcuLrl ie.
dcl liu, prclirrnd sirpfczortlln ciilcv0cLrnoitinleofieniative i l c de bol nrvi icu afccl i unincuR )l ogi cc ocnl rol c. ,
.rsLrpru rccstuidomcriu Iinlind coDrdc consrtar€r cI de hpl {r.l r rrrtr,nrr Lrr :r I r (Jr J( i J u:,.i r r.,rI J\J ri n,,r( J
lt.ausplantLrl cardiac fcprczrntl o prdcarccrrdiLrcl lolaln. ccocudiosralicii nicrior prclcvat|iicordului drc cr scopex'
Flcogralit nsplantuluicdrdi& ctrpriDdclrei u risecliutrr. cIderea unorri'ectiunicardiaccnccuDoscurc dc cilre arrumi,
Prlrrlldintrc sccliuniscrclcri la ccogralirdonorilorpoten- rllctlluri carc ar putcr eonrpr(nnilcrclultdlclc ltuosplantrhri
tialiiia recipicnliktrpotcnliali.cuprnLandin lhpl ex.rrninarF cxrdi ocsrLrchi arsi taci i mposi bi rccsr l rrdnspl .nrcnrdi ac
le ecocffdiograficc cl.!ctuatcinaiDtcdtunsplrnlului cardinc. Lisla diverselof xteetiufi c rc pol li dcpisrI]tcc(c com-
Lea de a doua s.cliunc sc roltri h rspcctclc ccocrfdio plcrl. poflrrndde la rfecliuni congcnitalcii piDi l.t hrclc
gn ice ornrle inllilnire la bolna!ii rranspldnla(i.ntcluzrind miocardicesile|!ioase.d.rrnrdeoscbicardiom()pxtrilc,xdc-
uncl cd i n l rcc om plic aliile ,.fi z i o l o g i cnco" td rch n rc d D u scori cu clolulie insidioasaNnt cele carc trcbuic cxcltrscin
jorilrle 0 bolnavjlor supu$iunuihansplant carchd.. prinrul rind la donorii potentiali.
In sle$il cea de a rreia secliunc sc rc1 ri lr scmnclc in aldoilcr rend hbolmviicu stafecomrlr)as,tosr rratr
ccocrrdiogralice ale coulplicatiilor apirutc la bolnr!ii cu m.ticn. cnc ncccsff exclud.-rea inercsiri i cardiaccsccundrrc
trlnsfhnl dc cord cea rnxi redutabili fiind rcprczcnlnlaidc naunratismului$lcir de donorii potenliali [21.
r.icrul lnDspl.tlrlulur. AstLl ccocrrdiogrxlx poale depista contuTii cardiacc
Ecocrrdiogrrlia pretransplant cardiic (prin modilicdrcr ccoddrsolii miocardului $i prin tLrlburari
Aia cum am Lrrilalsc reltrl la exaninareaecocardiogra- segmcnlafcdc contrxcrilirar) ca $r colecl! pericard'ccscm
nc.r r donorilor potcnliali s.irecipienlilor potenljalj. nificative(hcmopc cr ).
Ecor d/d iogruJie 0 a nspI dntulu i ca,.liu( 311
La bolnaviicuafectiunieurdogice(comevascularc-.tc) rAndprin consecinlclc srle. respecti!rczistenlele vascutarc
moddicarilc cardircenrpfrmxlrind clcctrocardiogralicc sunt pxlnonarcprlnbiopsicpulmona|i.deoarccc cre$erca pestco
frecvente sugerAnd inlcrcsarea cordului!ccstorbolnavi.Dac! anumitnlimni (pesteopt unitirtiWooda rcristcnlelorvascx-
I'ncm contii de verslamai marea bolmrilor cu astfeldc larepulnronare) poatecomprcmne rezullaNlch.rnsplanrului
sulcrinlcsugestiauneicardiopltii oqanicecstccrcscuti.De pnn realzarcauncibariere..insumontabiLe in hlalcnlricu-
acccalaaceasticategorjc dcdonoripotentiali cstcnccesari in luluidrept,cu rcapariliarapidd\ii impot1anla a lcnomcnetor
toatecazurilcexaminarea ecocardiogralici pentrua cxclude dc insuficient[cardiacn dreapti.
afectixnicdrdirceshrcturale9i in primulrando cardlopatie Anatomiati perfornrnta corduluitrrnsplantat
carepoalccomproniterezultarclc transplantului. Serclcrnla aspectele ccocardiografice nomraleintehire
'schemlci
Ir rfu-J rce.terJramr1i,1ecocdrdr,,fr,rife in.cop la bolna!iitra splantati, incluzerrd unelednrte conipticafiite
linritarivla potenlialiidonoi. exa,ninarea arc intr un pro- n,'rrreld bulna\ii ,upusiunu.rrdn.tlJnr crrdir(
cenlal cazurilorfi un etectbcncficde creiterca ntrmnrului Pentruo mai brni intelegere. snnc reanintimliiptulcir
potenlialilordonori.Ne relbnm la situatiilein carcdatele lransplantul de conl u csteun ransplanftotalSrci seprc-
clinicesugcrcazA o posibildat'eclarc cardia€d saxo posibili zervno pate din atriulstlng $i atrixldrcpl$i vaselemaridc
rnleresare traum{rtictr cardjaciti dcci inutilizareaininrihr la bazainimii, de aceeain anumiresirua{iisc pot evidenlia
polcnlialilordonoripcntmtransplant. iar ccocadiografi avinc ecogrdiic liniiledesuturecarcnufebuiecontirndnrccu€coufi
:a J,^eder,cJcadc thplInrmrle nu sunl0lc!lrteorgrnrc)l Patologlce 12.31.
pol6 lillositepentrutransplantul cardiac. O altAFoblcnrlestelegatidc laplulca.in general, inimile
Tolincadrul acesteisecliuni.recocardiograliciprctrans- Iacareseindicntransp lantulsunrmuhdilatate. Transplanriind
planr trcbuic amintiti ti examinarcrecocardiogreficA a o iniml dedimensiuni normaleintr-ocavilarededimensiuni
recipienilorpolcnlirli. crescutcaceasta se poatcdcplasagi, de rcguln.esterotattr
Nu dorimca in acestsubcrpitolsAreamindmindicaiile Tnsensoror,incBtexaminare0 ulilizAnddiverscaborduri9i
deransplantcardiac, dardorih sasubliniemfaptulcetftns- ferestre poarcti diferitathli dc cxuminarca normali.
plantulcardiacse indictrin rtadiulniop&tiosl bolilorcar- Trcbuie.deasemcnca, linutcont,lndcoscbi la nivelulatrii-
diovnsculare $iln primulrandin cardiomiopatiilc idioJ)arice lof 9i in spccialla nivelulalriuluisdng,caaddugarm cavirati
(cafdiomiopatic dilarativA).in momcrtulin carebolnaviisc transplantate l6 ccarcmanentdpoatc duocla cretterea dimcn-
afll clinic in clasafunclionnlaNYHA IV irr din punctde siunilorcrvitali restcctivcin afaraoricdrcipatologii.
vederealpcrfonnanleisistolicc gk)brleaveolriculului stAng Unalt aspcciimportantdcscmnalat estedilslarca venrd-
lracliade ejcclicscadc< 25-20rzo. culului dfeptal inimii transplantalc, dilAtare
.,tiziologicd".dn-
Bineinlelesdatelcccorardiografrce trcbuiccorelat€cu lora[ hipcrtensiunii pulmomre.Pdnila nonnalizarea, pepar-
dateleclinicc$i. in primulrandcu lipsnde rtrspuns la rrah- cursulmaimullff strptAmani. a rczislcnlclof vascularc pulnm-
mcntiide ameliorarc8 pcrfonnaniei sisloliccI ventriculului narc,vcntricululdreplpofltcdman€dedimcnsiunlcr€scutc.
stang,subun tratamentmedicsmcntos corectcondusii in Putemconstata de asemenca o cre$tere a dimcnsiunilot
primulrdnds"'(unJurltJmrnrstrcni Jc rnhibuonai enrirDri rcspcclivgrosimiif,crclilorventricululuistAng, caresednto-
dc c1)nv€rsi€ Sidebekblocantc. reaztrdc rcgulaedetnlrluimiocnrdicrezullatpc pnrcursul
ln situslirin careseia in considcrar€ in bazaecocardio- rccoltarii9i mrnipullrii inimii tnrnsplantate [31.
gmficletlctuarea tfltnsplaniuluicardiac, cstcncoesarde cele E(ogr fir in Tl,,l )r 2D re dovede\'urilc in aprecier(a
marnultc orica aceslasafieprcccdat deo biopsiccndomio- Drorfologici corduluitransplantat. UtilizareaSi a tchnicilor
cflrdicacare si cxohrdianumite cauzclcrapcutice a1einsull, Doppleroferadetcsuplim€niare privindfuncliavenrdculari.
cicnlcicardiace severe Sjsdsugereze beneliciul rrnnsplantului cet9i gradulinsuficienteimitmle ii tricuspidicnc.Nocinte.
cardiacNc rcfcrimoici in pnnul rind la miocardilc.Dc Pcrtbrmenl!ti rnatonir venrriculului stang
ascmenea, aceastibiof,sic poateseidentiliccanumitecaxze Maioritatea studiilorconfirmnfaptulcI pcrfbrmanfa sisro-
carc rcahzcazarnreresarea nultiorgan(nuftisislcmicn)ti licaSidimcnsiunile ventricxlului sdngsuntin limrlcnornale
car€lirc inulil trinsplantulcardiacavAndin veder€evolulja la ccitransplanilfi, dac,bineinlelesnLr ausurvenitcompticlrlii
ncfavorabila a cMurilorpu aparitiainsulicicnlcila nivelul majore.Astfel s-auraporlatvalori ale ftacticidc ejecliea
altororyanc$isisteme. vcntnculului s6ngdepeste60%la ransplaniali. uneletrialuri
Deascmcnea. lrebuieelbcluaula aceitibolnavievaluarca taportand chiaro perlblmanl,sisiolicnsupcrrcaria cordnlxi
re,,rsrenl(
l.r pulmonJre. in rorrr.azurilern crreprn rto- transplantat comparativ cu persoancle normale.
cardiografie iiinprimul rend prin eco-Doppler sedcpistazi Funclia diastolice a cordului transplantat estemodifica€
hipe{cnsiunea pulmonarn aceastn lrebuieevalxat{in primul chiarin lipsaunorcomplicaliimajore(de genulrcjetului).
l7N t,r.grdhd Lofttultliti tuschr d? lo ba2aitinnli

hanrcnul DopplercoDsra|.anomaliide rchxarcdiss|olici. putin e\ idcDtc,cxarneruLDopplc. nc poateofefidat.lc cclc

cilLti lrleponrpelrtrirlc sugc..And o distunclic dirstdici detip mai uti l ..
rcl.rNrcnhefaia sauchiardcdpreshciil ca.cDucs|crcalirL'll. SeDrnclcdc rc'jclin ecocadiogrrlir 2D Sr-TMsurt:
Perlbrn'rtr1ati nnrtonia ycntritulului drept . ilrgror{r.r pdcLclui ventficLrluluistilng
\tnrricululdrcplti cordultranspl.nltlcsle ririt in . creitere. ccogcnicllalii perelelui!cnrricLrluluisrang
dxnensiuni. in prinele siptimanifosl nrterventie (probabil . creiterc{ nusci lcnlricxlare
.(.Ln,l.,r |l.nLrr<r..trri.arr. r.,ht,.lnuur<e\i.reIrJ,,rrrJri ' aparil r saucrcfrdu vohrLinrlui utor colcclii pericardicc.
'.r:.r')r l , 'L.1. .../ur.cl! rl.,re' Elamin{rca Dopplersedoledeilc cx(run de fiili in diag
t1:rl.<Iri'
miri6 d rp indelungal. nosticarearcjclul ul acut.exanrenulDopplcr d flnx ului
'nitrtl
Strdijle1)opflcrauconfinnato ugorrn!ltdrrc a pcrlbr- ii tficusfidian co stati nrodilicairidc lip restricrv (scurLrrca
rar(ejsistoliccti diaslollce avenlricululuidrc'plin perioada tnnpuluidc rela\are iTovolumctrlcn.a PHI iii r cclul dc de'
ilnedirl posttr'{nsplan1, foal1ec!iclcntnh incarcafea vo]u cclcrxlic nitral ri ricusfidirn, creitereaanrflitudrnrl undei
nrioi.altcrurccares-arpute{drl(m clcclelofsecundarc rlc E a lluxuhri diasntic. ctc). t-in trnianlenlprccoccal reietului
hitcrtcsi nli afteriale pulnronarc, darti unof{nomaliirlc poale si condu.i h nonnalizareadatclor Doppler. tehnrc.
InncliciatfialedrcFc f4.sl. dovedindusc asLlclextrem de uliln iD monitorizafeaaccsl(n
Perfbnn{ntr !ii :rn.rtomiaatriilor p:rc(ntr .r rr.l .r(:rr.r' enrn,nrrrr rrurnarr.l d< bi ^f.' ni ,'
Datoriti suturilorchiruryicalecarc intcrcscruaatiile. crrdicc. Dc ascmenea.tehnicacslc dc r:rrefolos in situdtii
tu nrln.rtrans|lanluluiapafInodincn.idc lbflni a acesior cind bn)psianLrestepracticlbill. sru canddatelcbiof'licc nu
cavitnti.,\ccslcmodiliciri sunl ccl m{i bine viaralizatenr $,nLconcludentel2l.
ecogr{lldlransesolhgianar. carcporlc cviderrljarelativulol O propo4ie N trcicn(ilor Lransplantalidczvohi lardiv o
li iilc dc snturi intrc rtriul rcccplortj alogrcfi. Accaslii cardionriopaticdc lip rcslrictiv, crrc NaLc Ii dragnoslrcdl.'i
dc arcarese poatcscsiz.rfi la nivelul sef'tuluiinlcmLral. la ex,r'ncrrulDopplcr Aceasti cardk)miopalieevoluerzi in
cxistinddifcrcnlcdc srosnneirrre septulprimiLorului \iicel ti rf' cu {ltcr{rca lirnclieirinolicc rigcncreazddc ascmcnca.
alalogrcfci.Pscudo{ncvrisnrele descplirltcr{lrial sulrlrel0lrv
trccvcnlcpos(lrarrsplaul. Col€cfia pcricardicl
lcoc0rdiognfia norlc idcnLiilcr dissincrSll inlrc rcLi- D aci col ccl i r pcri cA rdi ciera semnrl dl rcl ati ' rar l a
\'ilateaahiuluircccplor ii ruspcotiv ccl I grclci.Accasrl1 paci cnl i iposttranspl ant cardi rc.i narrl cauti l i Tnti i i nruno -
disocirlic poalc derernrind apurilia !ii Lrombilof intlaalrirli, suprcsoorelor eficicrllc. Aclurhncnle se $cnrnrloAzdo ioci'
loc0lirali ir)\,ccinart{tca sulurii. !izualizrbili ccocrrdiogr.rllc dentl crcscutl { aocslcia (de panii la 45rld).10ceitf.rtall cu
(nrrirlcsjn lr rscsdhgian) [,1,51
Insuficientolc vAlvuhrc I cidentacolccliilor pcricardiceeslc mull crcscLrlila cei
lnsulicienia nritMll cst0liccvcnttr posttrurrspltrt.tchnicrlc cu re.jetiii h p0oicnlii raosplantali pcnlru cardiomiopnlic
Dopplcfh.rnscsolitgicnc liindsupcri(xu c cck)rlrrnslor0cice ilr di l A l al i vlpri ni l i !l i [2.61.
idcnlilicurco ci (LrneoIi insulicicnlami(ralI poarefisccundarn Cardiopatir ischcmici
prcl.tpsulLri volvukrr). S e a| rcci l i ri cI pcst€ l /3 di ntrc i ni nri l c tmnspl nl A lc
lnsuijcicnl.trficLrspidirnA cstc raportoltrla o propo(le tr..,,i nril,.rr< r Ir' n. sl ru r.nl rrr b,' dl rcoron.rl Jni ii I ur' .1(
marcdcprcienliinrediatposttr.rDsplanl. dnrinoidcnlaci l{ l cazuriaceaslasc nr\talc zlchiafnr pri,nclc luni pos|operator,
mesteaproximdri! 33-35'/"(esteirrtlilnitlnr spccial ln ceicu gencrtrrdiDsLrlicicnF cardi4cluncoricxlrcn d€ severh.Dco -
hipcdcnsilrrc arterialapulmonariscvcrnii corddreprnrant rccc sinpromele de angini pcctorall suni AbscnlclN cordul
prclrLrnsplant). lislc mai liccvcnlde gradull-ll.1iindnr rdrc transplanlat(dcncrvaI scnzitiv),diagnosticLrl ccocffd iografic
caznrisccundarn prolapsului vahulaf lal. al bolii coronarieneeste\'ilal. Acc.rsLrpoat€redLrccnumlrul
Complicatiisocundrrctransplrntulni cardirc cxdnin.riLor invazi!c (c.rcrcrislnelod 17.81.
Rejctulgrclti Ecocardiogralidbidi lensionalapoalcdccch molnaliide
in nccuL.nr pcrioada ecocardiogrrli ci in TM. seftreiede kirclicl prrielali. Dacaaceaslicxrlninarerx esteconoludcD
rciclal greleierauconsidcrdrc scldcreaamplitudinii conrplc ln sepoaterecurgcla coocardiograllade strcsoarcprezinti o
\elor ventricularcpc ccgiicreitereaecogcniciullii pcrctclui sensibilitatcsupcrioardelectfocardiogrumcide efort
posrcri{)r la
rl lcnlriculullrisling ccogralia in TM (daroriti haluarea optimi se r..rlizcua pnn examlnarcaultrdso
inlillratuhri $i ederrului). nicn intralasculari. r' oLdcauauiLlizatain rvrcrcr€ cu cate-
AcrLralrnerte seoonsidcri ci lnai ales la p.rcienliitratali ierismelc cardiaccrcpetale calesunl aplicalcrcesiof bolnavi.
cu nnunosupresoare. la carc scnnclc de rejet sunl nruk mai gxaminarca cco ii Doppler inravascL'lrrane poaie arita l)c
f ;oerJtu{ aho tranVlantului .utJtrr
dc o pate modificarilc slrncturalea1evaselor coron{ricne.
tar pe de alia parle nc pcnnitc studiul tonusului \xvnnotor
rl rceslorain conbinalic cu anumite probethnnacodinrnrice
(proba cu acerilcolin.i)f9l.
I)epistareaingro'sirii intimale i| Fralcl cu fcducerea
tonusnlui !asomotof (modificareadiancrrului li probelecx
lasodilahroarc)pol constitui un rnarker31disfuDcll.iendote-
lia1eii al posibilci rtrrilii in t irnp a aler$clcr)7c I accelerate
la nivelul cordultri transphnrat.
Hipertensiunea arterirlir
Sernstalcui la rtrcapeloli pacientiilnnsphntati h"rati a
l: r lonp. r . J i .h * I' ,, i n l .l l n d i .1 1 rt,rJ l (n rr l Jr.i m< ri l
pe azahoprini.prcdnisonsou alle inunosnprcsoare
( - on. . \ in t:.J i r< rri J h i p e n c n ,i u rr rr. rrcrrerernrrtr
lcntricuhrc. cauTatoarela rirdul ci dc cre$tercaincidcnrci
arilmlik)a rbolii coronariene.ainsuficiclei cafdiace,nlorLii
. U\ ir ! . r r . . If.' c .,rd i u Eri i J L ' r( u ri l i i , (x l cr l rr(.r rrr.,' .1
vcnlricLrlare$i orai ales in aprccicrcr lciderii accslciastrb
lrallrmcnl hipotensorclicicnl
37t
Bibliografie
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dr)sruthy rorL e{rl} dlior cttrdrc t,r'rr mr{LiotrDrcdids dNclor
nrcrl o iooclc(10(l illogrrn flrctrur dtcry (liscdsc.( rc'lrlion