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Valvulopatiile adultului

Etiologie

SM
ETIOLOGIE
~RAA pancardita
Inel:
Cuspe: groase, retractie, fuzate
Cordaje: groase, scurte, fuzate
N.B. Calcificare: ~B, varstnici, gradient

Calcificare anulus/cuspe (=ocluzie inflow VS)


Congenital (ex: absenta unui papilar etc)
Alte cauze: tromb/tumora AS, vegetatii, postchirurgie
(MVR, comisurotomie), boli metabolice, carcinoid

Epidemiologie:
F>B
Tari sarace>bogate

IM
ETIOLOGIE

Degenerescenta mixomatoasa (floppy leaflet) ruptura idiopatica de cordaj fara floppy leaflet (defect
fibroelastic?)

Cauza congenitala: defect fibroelastic (inel, cuspe, cordaje) familiaritate


F>B (normal); B>F (bolnavi)
Asocieri: HTA, EI (doar la cei cu IM)
Ingrosari fibroase focale (aspect AS) si intercordaje (aspect VS) cu extensie pe cordaje pe cuspa prolabanta;
ingrosari fibroase pe inel si dilatare
~dilatare inel + elongatie/ruptura cordaj I
N.B. Ruptura cordaj: ~posterior, cauze (degenerescenta, disfunctie papilara?, EI?)
HP: fragmentare fibre colagen-elastice, MPZ acumulat

Functionale (valve normale): CMP ischemica, dilatativa

CMP ischemica:

Fuziuni minime comisuri si cordaje (#SM); dilatatie asimetrica (posterioara) inel; ingrosare si retractie cordaje si
cuspe cu calcificare minima

Calcificare inel mitral

CMP dilatativa: inel (dilatatie prin dilatatie LV), papilar (repozitionare prin dilatatie LV)

RAA

Cronic: inel (dilatatie prin dilatatie LV), papilar (repozitionare prin diskinezie/dilatatie LV; fibroza/retractie ischemica)
Acut: (IMA inferior>IMA anterior): inel (dilatatie sistolica), papilar (repozitionare prin diskinezie LV; ischemie ~PM papilar
ruptura necrotica 2-7 zile post-IMA)

Varstnici, F>B
Cauza: stress hemodinamic? (asociere cu HTA, CMH, SA)
Alte asocieri: DZ, IRnC, calcificare inel aortic, embolizare calcara (rar), BAV
Calcificare inel posterior calcificare inel intreg, portiuni periferice cuspe cu aspect concav si intindere cordaje
defect contractie sistolica inel si defect coaptare prin imobilizare portiune periferica cuspe

Colagenoze, fibroza endocardica, EI, trauma toracica


Congenital

Tip I: miscare cuspe N


Dilatatie inel defect coaptare CMP dilatative, unele ischemice
Perforatie cuspe EI
Tip II: miscare cuspe prolapsanta
Elongatie/ruptura cordaje, floppy cuspa IM degenerativa
Elongatie/ruptura papilari unele CMP ischemice
Tip IIIa: miscare cuspe restrictiva in diastola
RAA
Tip IIIb: miscare cuspe restrictiva in sistola
RAA, CMP dilatative, unele CMP ischemice

SA
Etiologie:
Calcific degeneration = MOST
Causes: age (>70y), congenital (<70y) (uni-/bi-), CRnF,
bone Paget, ochronosis with alkaptonuria (greenish
valve)
HP:
Congenital: microfibrils defects in leaflets/root
chronic inflammation + lipid deposits + ACE stimulation
calcification/fibrosis
Start: leaflet bases rigidity + annulus, root
Atherosclerosis RF Statins? (stop progression? # Stimulates
calcification?)

Rheumatic
HP:
chronic inflammation fibrosis
Start: commissures fusion, scarred leaflet edges

Congenital, Etc.

IA
1.

Leaflets lesions:
Degeneration:

Calcific: age, bicuspid


Myxomatous
Anorectic drugs, carcinoid sdr

Vegetations/inflammatory retraction: Rheumatic fever, IE


Prolapse (flail): VSD
Disruption: IE, aortitis, DiAo, trauma

2.

Root geometry:
DiAo, trauma, HTA, bicuspid
Aortitis:

Infective: syphilis, viral


Systemic (Takayasu, giant cell, Reiter, PR)

Connective tissue (Marfan, E-D, Reiter, PR, osteogenesis


imperfecta)

IT, ST
Etiologie:
Functional: ICD IT
Organic (ST>IT)
RAA> EI (drogati)
Congenital (+/- DSA/DSV)
prolaps/elongatie/ruptura (Marfan)
disfunctie papilar (infarct VD)
colagenoze, leucemie eozinofilica, sdr
carcinoid, trauma (inclusiv pacing!)

Diagnostic

Diagnostic

Clinic
ECG
Rx toracic
ECO-Doppler (ETT<ETE) = dg, severitate
Cateterism
Drept: HTP reversibil?
Stang: suspiciune BCI, discrepanta clinicECO sau ECO-Doppler gradient#arie

CLASIFICAREA SEVERITATE SM

Usoara

Medie

Severa

AVM
(cmp)
N:4-6cm2

>1,5

1-1,5

<1

GM
(mmHg)

<5

5-10

>10

PAPS
(mmHg)

<30

30-50

>50

Clasificare severitate IM
CRITERIU

IM USOARA

IM SEVERA

Ajetcentral

<4 cmp

>8 cmp

Ajetcentral/AAS

<20%

>40%

Vena contracta

<3mm

>/=7mm

AOR

<0,20 cmp

>0,40 cmp
(>0,20cmp IM ischemica)

VR

<30 ml

>60 ml
(>30ml IM ischemica)

Flux sistolic VP

Sistolic>diastolic

Reflux sistolic

Semnal DC

Aparat mitral

N/anormal

ruptura/flail cuspa; ruptura


cordaj/papilar

DAS

(fara alte cauze)

DVS

(fara alte cauze)

Clasificare severitate SA
AS

AVA

AVA

mG

pG

pV

(cmq)

(cmq/mq)

(mmHg)

(mmHg)

(m/s)

>1.5

>0.9

< 25

<3

II

>1

>0.6

25 40

34

III

</=1

</=0.6

> 40

>4

N.B. Normal AVA = 3 4 cmq!!!

Clasificare severitate IA
Severe AR (integrative approach ESC
2012)= Holodiastolic flow reversal in
A3CH
Color: Large central jet, variable IF excentric;
Vena contracta >6mm, EROA>/30mm2
(Nyquist 50-60cm/s)
CW: dense, PHT<200ms, RV>/=60ml
2D: LV, coaptation defect (large, flail, abnormal)
PW (descending aorta) : EDV>20cm/s

Holodiastolic flow reversal:


abdominal aorta

Clasificare severitate ST/IT


ECO (Doppler, 2D):
TR:
(diastolic)
annulus>/=4cm or >/=21mm/m2; (mid-systolic)
coaptation distance>8mm (A4);

coaptation defect (large, flail, abnormal),

Color: Large central jet >8cm2, variable IF excentric; Vena


contracta >7mm, PISA>9mm, EROA>/40mm2
CW: dense-triangular (early peaking, NOT parabolic),
peak<2m/s, RV>/=45ml
PW: E-dominant>/=1m/s, systolic hepatic flow reversal

TS: mG>/=5mmHg
RV: TAPSE<15mm, TASV<11cm/s,
RVESA>20cm2

Normal tricuspid flow in A4: biphasic


above zero line

Normal tricuspid flow in PAS:


biphasic above zero line

Severe TR

Normal suprahepatic flow: triphasic, predominant


antegrade

Suprahepatic flow reversal

Severe TS

IM
Management

TESTARE PROLAPS CUSPAL

PROLAPS

TALAZ

Banda Cosgrove-Edwards pentru

ANULOPLASTIE CU INEL
Anuloplastie cu inel (rigid/flexibil; complet/incomplet):
Ubicvitar in IM?
curativ/preventiv anulo-dilatatie, intarire suturi, crestere
coaptare
Fire mattress inel protetic inel valva pe anulus posterior

Dezavantaj: lipsa contractiei inel in sistola hemodinamica? (gradient); SAM (inel


sintetic pe inel anterior nativ)?

Varianta MASS (mural annulus shortening suture) hemodinamica better?


Durabilitate? (Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University,
Frankfurt/Main, Germany ; J Thorac Cardiovasc Surg 2006;131:99-106 )

Avantaje: NU SAM, NU
hemoliza!

SAM? Carpentier
var

REZECTIE CVADRANGULARA
+ anuloplastie
Mobilizare (lungime margine cuspa ~ inel
posterior) cuspa anterioara NORMALA!!!

Anuloplastie plasare fire?, inel


calcificat?

Neocordaj
Indicatie: cordaje ruptura/elongatie (NU scurtare/transpozitie
cordaje)

Goretex ( endotelizare, lungime ct in timp) # xenopericard


tabacit

Scurtare cordaj prin sutura-pliere


cordaj pe papilar (French
correction)

Alfieri
(edge-to-edge, dublu-orificiu)

N.B. Rezultate: supravietuire 95%/5ani; reoperatie: 10%/5 ani (Alfieri


2001)
N.B. Alfieri fara anuloplastie < Alfieri cu anuloplastie (Cardiac Surgery Division, IRCCS
San Raffaele Hospital, Milan, Italy J Thorac Cardiovasc Surg 2003;126:1987-1997 )

Sliding-plastie de papilar elongat


Indicatie: elongatie grup cordaje

Splitting papilar

Rezectie cuneiforma de papilar


elongat

Concertina technique in papilar


elongat

MECANISM SAM

Anuloplastie cu inel fara indepartare exces tesut cuspal


SAM

SM
Management

MANAGEMENT
Modalitati:
Medical
PMBV
Chirurgical: MVP (~comisurotomie); MVR (valve
calcificate, fibrotice OR aparat subvalvular fuzat)
Aborduri diverse:
Miniinvazive: sternotomie superioara; drepte (parasternal;
anterolateral toracotomie) +/- CPB central/periferic
Clasic: sternotomie mediana

Asociere: maze (cut&sew OR energie) (FiA); anuloplastie


tricuspidiana (IT 3-4 +/- HTP)

MANAGEMENT
PMBV
Indicatii
Simptomatic + SM moderata/severa + X (I)
Asimptomatic + SM moderata/severa + HTPSrepaus>50
(HTPSefort>60) (OR newonset FIA (IIb))+ X (I)
X=valva pliabila/noncalcificata; IM<3; tromb AS absent
Intens simptomatic + SM moderat/severa + CI/risc mare
chirurgical + valva nonpliabila-calcificata (IIa)

Contraindicatii:
Non-X
SM usoara (mild)
Complicatii: IM>DSA, perforatie VS, embolie, IMA
Rezultate: mortalitate<1%, AVMx2, 50%GM,
rezultate bune pe termen lung

MANAGEMENT
CHIRURGICAL: MVP; MVr (rar: comisurotomie,
decalcificare+/inel IF IM asociata)
Indicatii (MVR, rar utila MVr!!!):
Intens simptomatic + SM moderat/severa + PMBV (NU exista, NU
morfologic, NU tromb) (I)
Simptomatic + SM moderat/severa + PMBV (NU IM moderat/severa)
(I)
Minim/0 simptomatic + SM severa + HTP severa (PAPS>60) + PMBV
(NU exista, contraindicat X) (IIa)
Asimptomatic + SM moderat/severa + embolii recurente sub
anticoagulant (IIb) doar MVP!!! morfologie favorabila
N.B. Pacient cu risc acceptabil chirurgical in toate cazurile!
N.B. MVR cu pastrare cordaje sau neocordaje!

Contraindicatie:
Minim/0 simptomatic + SM usoara/medie + HTP usoara/medie
(PAPS<50)

Complicatii: proteza, anticoagulare

MANAGEMENT
MVR: selectie proteza biologica # mecanica
Mecanice: dorinta non-reoperatie; anticoagulant pe viata
(FiA cronica); NO biologica (IRnC; Ca)
Biologice: dorinta non-anticoagulant; NO anticoagulant
(lifestyle, HDS, sarcina viitoare etc); varsta > 65/70y
(degererare precoce <40y)
~heterografturi cu stent
Heterografturi stentless (pericard bovin) (promitator)
Homograft: endocardite la tineri (rezultate indoielnice chiar in
centre specializate) (papilar la papilar; inel la inel; + anuloplastie
de acoperire cu inel)

N.B. Supravietuire IDEM; morbiditate protetica:


mecanica>biologica (primii 7y); THEN opus ( necesitate
reperatie pentru biologice)

REZULTATE MVR
Mortalitate (biologic=mecanic)
precoce: 6% (AVC, hemoragie, insuficienta organe:
cord, pulmon, rinichi)
Tardiva la 10y: 50% (TE, hemoragie prin AC,
insuficienta organ: cord; CICD)

Risc operator: HTP severa+ICD (insa se


amelioreaza dupa operatie cu HTP!!!); varstnici;
NYHA; CICD
Morbiditate:
TE/colmatare, hemoragie prin AC, disfunctie proteza,
leak, infectie protetica
Reinterventie la 10y: VM biologica, MVP>MVR
(deteriorare proteze biologice >50%/15y)

ST, IT
Management

INDICATII CHIRURGICALE
Severe TS + symptoms/cardiac OP (I)
NB Surgery>PBV (rarely in severe TS TR risk!)
Severe TR + cardiac OP (I):
+Moderate TR (primary) (IIa)
+Mild-moderate TR (secondary) + annulus>/=4cm (IIa)

Post-cardiac OP: severe TR+symptoms/signs RV


(NO severe RV/LV, NO severe HTP, NO other valve)
Severe TR (primary, NO severe RV) + symptoms (I)
+asymptomatic + signs RV (IIa)

EI:
medical failure (sepsis persistent, IRn la drog, embolie
septica, ICD severa),
uneori (vegetatii mari, BGN/CA, vegetatii si in cord stang)

CONTRAINDICATII
CHIRURGICALE
Relative:
HTP>60mmHg (mai ales in absenta afectarii
stangi)?

Absolute:

TRATAMENT CHIRURGICAL
TVr:
Comisurotomie ST
Bicuspidizare (reducere inel la nivelul cuspei posterioare) IT
2+/3+
DeVega anuloplastie (reducere inel la nivelul cuspelor anterioara
si posterioara) IT 2+/3+/unii 4+
Anuloplastie cu inel rigid/flexibil sau benzi IT 3+/4+ (BETTER
THAN DeVega!!!)

TVR : bioproteza (exceptional homograft


mitral)>mecanica (risc tromboza, survival idem!!!)
Debridare in EI +/- reparare cu pericard concomitenta +/+/- 0 (+/- TVR ulterior)

TVR cu conservare cuspe

Pledgeted everting-U
Bioprosthesis

Annuloplasty De Vega

Failure guitar string

Antunes

Bicuspidization

Minale

DeBonnis edge-to-edge, trefoil

SA
Management

Surgical indications (ESC 2012)

Symptomatic + severe AS (I) (NO limit for EF IF mG>40)


low flow, low gradient ( EF)+/- flow reserve (IIa/IIb)
paradoxical low flow, low gradient (EF=N)
High-risk (Euroscore20? or STS>10?, porcelain aorta?, Rx
chest?, patent CABG?)+severe symptoms (IIa) heart team
decision: S or TAVI

Asymptomatic + severe AS:


CAD/Valve/Ao (I or with moderate AS IIa)
Critical AS (IIa):
pV>5,5m/s
calcification + pV-progression>/=0.3m/s/y

LV impairment :

EF < 50% (I)


Stress*: symptoms (I), hTA (IIa), +mG>20mmHg (IIb)
Pro-BNP* (IIb)
LVH*>15mm (no HTA!) (IIb)

SD risk: VT ? (AHA 2006)

Surgical treatment 1
AVR>>AVr
Types of approaches:
SM
MIS, RAT (+femoral CPB)

Types of prostheses:

Mechanical valve: age, AC, preference


Biological stented valve: age, AC, preference
Biological stentless valve
Ross: <50y
Homograft: IE

Types of AVr:

Surgical treatment 2
TAVI (risk+severe symptomatic AS heart
team)
Types of approaches:
Apical (antegrade) CI: EF <25%
FA (retrograde) CI: PVD, </=6mm(18F)
LSCA (retrograde): CI: PVD, </=6mm(18F), patent
LIMA
Rarely: ascending Ao

Types of prostheses:
22F/24F Edwards (all),
18F CoreValve (LSCA/FA)

Cribier-Edwards valve consists of three pericardial leaflets sewn to a stainless-steel


stent. The valve is stored in the open position to avoid damage to the leaflets (left panel)
and must be hand-crimped to the delivery balloon (right panel) immediately prior to
implantation.

The Corevalve system consists of pericardial leaflets attached to a self-expanding


nitinol frame. In the deployed state. The flared distal end assists in anchoring in the
ascending aorta. The stent covers the coronary ostia, but cell size is designed to allow
later coronary catheterization.

M1 Starr-Edwards

M2

M3

Mitroflow Pericardial aortic prosthesis (Carbomedics)


(G3)

Pericardium is placed
around the exterior of
the stent, presumably
allowing for a larger
opening diameter

SORIN PERICARBON STENTLESS

MEDTRONIC FREESTYLE

Full-root Technique

Complete Subcoronary

Root-inclusion Technique

Modified Subcoronary

Maximal approach 1cm to commissure or


RCA (first try to see the origin of RCA!)

Risk of RV hematoma

Initial small transverse aortotomy may be extended transversely or


obliquely.

Injury

Aortic valve after leaflet excision

Aortic valve after leaflet excision

Muscular IV
septum RVOT
Anterior MV

Perforation
risk

His bundle
in membranous IV
septum

Commissure
Near
commissure

Nadir

Variant for M implants: 2 sutures aligning pivot guards toward RCA and
LCA = first sutures to be knotted

St. Jude Regent (R) - only pivot guards in annulus for any tissue annulus
diameter larger valve housing # St. Jude HP (L)

M3 St Jude Regent, supra-annular, only the pivot guards protruding


into the aortic annulus - LVM with all sizes!!!
Pivot guards in LVOT

IA
Management

Surgical indications (ESC 2012)


Severe AR (I)+ acute, symptomatic, cardiac OP,
EF<50%
Severe AR (IIa)+LVEDD>7cm, LVESD>5cm,
LVESD>2,5cm/m2
Severe AR+severe MR
Cardiac OP + moderate AR: status (age, repair, LV,
etiology AR)
ARR: >/=5,5cm (5cm: bicuspid+RF*, Marfan; 4,5cm:
Marfan+RF*)
(Cohn) IE (native valve) +

Annular/myocardial abscess, fistula


recurrent embolism (>/=2); vegetations >1 cm
persistent sepsis/bacteremia (+ATB)
BAV
AHF (III-IV), severe RnF/RsF

Surgical treatment
AVR
AVr

Operatia Bentall modificat

Operatia Ross

Simple I-I technique: coplanarity on aorta and PA!!! (4-0 Ticron)


NB: inner needle fully bites PA!!!

Cave: sinus matching!!! (posterior PA NC aortic