Post on 05-Apr-2018
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Note de curs
D.Spataru Sef de Lucrari UMF
Sindroame valvulare
mitrala si tricuspida
Diagnostic : stenoza mitrala ?
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Diagnostic Pozitiv
Etiologic
Severitate
Remaniere aparat valvular Asociere :valvulopatii/alte boli cardiace/ab
Functie sistolica vs
Htp Insuficienta cardiaca (NYHA)
Tratament
Indicatie operatorie
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Stenoza mitrala
Etiologia= RAA 99%
25% din RAA - SM pura 40% -boala mitrala
2/3 din SM femei
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Fuziune ap valv m in RAA
Comisuri (30 %)
Cuspe (15 %) Cordaje (10 %) (mai mult RM)
Combinatie
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Mecanisme producere SM
Proces reumatic mocnit
Dupa episod RAAfluxturbulent=fibroza,ingrosare,calcificare
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Alte etiologii
nu
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Fff rar
Valva in parasuta (1 pilier)
Calcificare inel mitral
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etiologii Congenital
Carcinoid (tricuspida)
Lupus
AR Mucopolizaharidoze (Hurler)
Boala Fabry, b Whipple
Amiloid Trat cu methysergide
Lutenbacher
Mixom,tromb,vegetatie
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Fiziopatologie
Normal orificiul mitral =4 -6 cm p
SM < 2 cmp / 4 mm Hg
SM critica < 1cmp / 20 mmHg
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Factorii precip aparitie dispnee
Effort fizic
Stress emotional
Sex Infectii
FA
(cresterea DC cresterea pres AS)
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Evolutia SM
RAA
SM (dupa 10 ani)
HTP Al doilea baraj
ICdr
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Manifestari clinice
Dispnee
Embolii
Hemoptizie
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Dispneea
De efort (NYHA)
Ortopnee
EPA
Asociere cu tuse,wheezing (scadere
CV,plaminul mitral)
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Hemoptizia (Wood)
Hemoragie brusca masiva (ruptura v b)
Sputa rozata in disp parox nocturna
EPA ( ruptura capilar alveola) Infarct pulmonar
Sputa hemoptoica din bronsita cr
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Durere toracica
Caracter de angina pectorala ( HTP,asociere CIC)
Embolii coronare (rar)
(neclar uneori si cu coronarografie)
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Embolii sistemice
20 % din bolnavii neoperati
25% din decese inaintea exist terapieianticoagulante
Corelatie cu virsta
dimensiune urechiusa stg
invers cu DC 80 % FA ( restul FA recurenta, EB)
( nu cu severit stenozei)
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Unde embolizeaza SM
50 % vase cerebrale
Coronare IM
Artere renale colica renala/ HTA Artere membre (Ischemie ac perf =5 p)
Tromboza masiva AS
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Endocardita bacteriana
mai rar pe aparat valvular f remaniat
Raguseala (sindr Ortner)
IC dr
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Examen fizic
Facies mitral
Dezvoltarea fizica a bolnavului ( obezitate)
Puls periferic diminuat,FA Pulsul venos jugular
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Inspectie
Miscare parasternal stg HTP dilat VD
VD f mult marit confuzie cu apex VS
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Palpare
Zgomot 1 intarit
Clacmentul de deschidere al mitralei
Freamatul (uruiturii diastolice) Palparea liftului parasternal stg (VD)
Palparea zg 2 - HTP
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Auscultatia
Zg 1 intarit si clacment deschidere m!!!!!!!!!!!!!!!!!!!!!!!!!!!
Uruitura diastolica ?
Decubit lat stg
Fara membrana stetoscop
Apasat f susor Pe soc apexian
Apnee post expiratorie
Dupa effort fizic
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Onomatopeea Durosier
RRRRRrrrrrrrrruuufffffff T Ta TaRRRR
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Criterii severitate
Aspectul bolnav
Gradul dispneei
Semnele HTP Durata uruiturii diastolice
Distanta zg2 CDM
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Remanierea ap valvular
Intensitatea zg 1
CDM
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Auscultatie dinamica
UD si CDM accentuate in expir
In inspir creste zg2-CDM = A2 P2 CDM
In picioare scade pres AS = creste zg2-CDM
(dedublarea zg 2 diminua in picioare)
Dupa efort zg2- CDM scade Valsalva diminua UD
Accentuare UD:nitrit,effort,tuse ,pe vine
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Dg diferential
Suflul Carey Coombs in puseu RAA
(Suflu dulce,proto diast,variabil zilnic)
RM pura suflu dupa zg3 Graham Steel (IP nu IA) inspir
Austin Flint (IA nu SM) zg1 intarit si CDM
Insuf tric/RM (inspir)
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ECG
P mitral
HVD
Devierea ax la dr corelatie cu severitate FA
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RX
Cord mitral: bombare arc mijlociu
Marire AS incidenta oblica
Marire AP,VD Calcificare ap valvular
Edem interstitial liniile Kerley B (pres cresc
in capilarul pulm) hemosideroza
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ecocardiografie
Etape dgclinic
.
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Etape diagnostic SM
Dg anatomic
Dg etiologic
Dg severitate
Dg afectare aparat valvular (scor W)
Dg boli asociate (valvulare, FA, tromb, CIC) Dg functie vs
Dg hipertensiune pulmonara
Dg insuficienta cardiaca Medicatie
Indicatia operatorie
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Etiologie SM
RAA Calcificare inel mitral
Congenitala
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SM congenitala
Valva mitrala in parasuta
Anomalie arcada mitrala
Orificiu mitral dublu
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Modificari morfologice eco(ALP)
Deformare si ingrosare valva mitrala Excursie limitata a valvei
Ingrosare si fuziune cordaje
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Modificare morfologica eco (ASPP)
Muschi papliar unic
Toate cordajele se insera pe un singurpilier aspect de parasuta
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Cazul nr.2
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Concluzii
Dg frecvent ratat
Etiologia congenitala
ST (gradient mediu diastolic)
Tromb urechiusa stanga (TTE 2C)
Examinare in ASP (pilier valva)
Rezultatele valvuloplastiei inferioare fatade SM RAA protezare
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Insuficienta mitrala
Etiologie si patologie
IM ac/ IM cr
Inel mitral
Foite valvulare
Cordaje Pilieri
Proteza
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IM acuta
Endocardita
Traumatism
Leak paravalvular
Tumora (mixom)
Lupus (Libman Sacks)
Ruptura cordaj (mixomat ,idiopatic.) Infarct miocardic
Disfunctie proteza
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IM cronica
RAA
Lupus ,sclerodermie
Prolaps
Calcificare inel
Marfan
Endocardita CIC
Cardiomiopatii
Congenital
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Manifestari clinice
Natura si severitatea depind de:
Severitatea IM
Progresia bolii
HTP
FA
Valvulopatii asociate Afectare coronare
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Simptomatic la bolnavi cu functiecontractila vs pastrata
Oligosimptomatic pina la deteriorarefunctie contractila
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Hemoptizia si emboliile sistemica
Mai putin frecvent decit la SM
Instalarea FA mai bine suportata decit SM
Semne DC scazut (Slabiciune, oboseala)
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Examen fizic
Palparea puls (dg dif SA)
Soc apex vizibil si palpabi pe sup mare
Hiperdinamic ,deplasat in stg
palpare zg 3
Expansiune AS (confuzie VD)
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Auscultatie IM
Zg 1 diminuat
Dedublare distantata zg2
Intarire P2
Zg 3 sau galop
Suflu diastolic dupa zg3
Suflu sistolic
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SS din IM
SS (holosistolic / incepe din zg 1)
La apex
Iradiaza in axila
Timbru : tisnitura vapori
Intensitate gr (1- 6)
Nu variaza intensitatea cu durata diastolei
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Auscultatie dinamica
Nu cu respiratia
Accentuare pe vine
Redus :Valsalva, in picioare
Reducerea ss dupa compensarea ICC
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Dg diferential
DSV
IT (INSPIR / semne Icdr)
SA
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ECG
P mitral
FA
HVS
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RX
Dilatatie VS
Dilatatie AS
Staza pulmonara
Calcificare inel m
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Ecocardiografia
Functia sistolica VS in IM
Regula 50
Dp/dt
PISA
Gradul (1- 4)
Vena contracta Aria jet reg
Reconstuctia 4 dimensiuni
Dimensiuni VS AS
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PVM
Exces diagnostic
Clic suflu mezotele sistolic
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ST
La bolnavii cu SM
Auscultatie in inspir
Gradient mediu diastolic > 2 mm Hg
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IT
Toti bolnavii cu Icdr
SS (accentuat in inspir)
IT severa : Puls jugular, ficat pulsatil
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Etiologie IT
Anatomica :RAA, endocardita, PVT,carcinoid, traumatism, ischemie,radioterapie
Functionala : dilatare inel HTP
Dg eco PAPS
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Evaluarea RM
Diagnostic pozitiv
Etiologie - mecanism RM
Aprecierea remanierii aparatului valvularAprecierea severitatii
Functie VS
Hipertensiune pulmonara
Leziuni asociate
E l i ii RM
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Evaluarea severitatii RM
Doppler color Dimensiuni AS, VS
Vena contracta
PISA Cresterea vitezelor undei E
Aspectul anvelopei Doppler continuu
Rerversul sistolic VP
TEE
Ecocardiografie tridimensionala
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Vena contracta
Grosimea jetului regurgitant la origine
Corelatie buna cu:
Volumul regurgitant (r = 0,85)
Aria orificiului regurgitant (r = 0,88)
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PISA
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PISA
PISA = Aria S = Flow = PISA x V (cm/sec)
2
2 r
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Doppler color
Distanta jet regurgitant
Arie jet regurgitant ( > 8 cm2
)
Raport arie RM / arie AS
Jet excentric subestimare 40%
Reconstructie 4 D
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A gresi e omeneste, dar ca s-o
zbarcesti in stil mare ai nevoie deun computer
Paul Ehrlich
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Concluzii
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Concluzii
Chirurgie in RM
RM severa simptomatica FE > 70%
dVS s < 40
Vol s < 40 ml/m2
RM severa NYHA I FE 60%
dVS s 45
Nu chirurgie RM FE < 30%
Controversa
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Controversa
Chirurgie pentru RM in CMD