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Come riconoscere le disfunzioni protesiche

Salvatore Felis. Come riconoscere le disfunzioni protesiche. TYPE. MODEL. Mechanical Caged-ball Single-tilting-disk Bileaflet-tilting-disk. Starr-Edwards Bjork-Shiley Medtronic-Hall Omnicarbon St. Jude Medical Carbomedics Edwards-Duromedics. Bioprosthetic Heterograft Homograft.

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Come riconoscere le disfunzioni protesiche

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  1. Salvatore Felis Come riconoscere le disfunzioniprotesiche

  2. TYPE MODEL Mechanical Caged-ball Single-tilting-disk Bileaflet-tilting-disk Starr-Edwards Bjork-Shiley Medtronic-Hall Omnicarbon St. Jude Medical Carbomedics Edwards-Duromedics Bioprosthetic Heterograft Homograft Hancock Carpentier-Edwards Ionescu-Shiley -------------- TIPI di PROTESI

  3. 17 7 33.4 ± 13.2 20.1 ± 7.1 19 100 35.17 ± 11.16 18.96 ± 6.27 21 207 28.34 ± 9.94 15.82 ± 5.67 19 63 33.3 ± 11.19 11.61 ± 5.08 23 236 25.28 ± 7.89 13.77 ± 5.33 21 111 26.31 ± 10.25 12.68 ± 4.29 25 169 22.57 ± 7.68 12.65 ± 5.14 23 120 24.61 ± 6.93 11.33 ± 3.8 27 82 19.85 ± 7.55 11.18 ± 4.82 25 103 20.25 ± 8.69 9.34 ± 4.65 29 18 17.72 ± 6.42 9.86 ± 2.9 27 57 19.05 ± 7.04 8.41 ± 2.83 31 4 16.0 10 ± 6 29 6 12.53 ± 4.69 5.8 ± 3.2 Normal Values for Doppler Echocardiographic Assessment of Heart Valve Prostheses: aortic valveposition Carbomedics Bileaflet St. Jude Medical Bileaflet n. Pz gr. max. gr.med n. Pz gr. max. gr.med Rosenhek R. Journal of American Society of Echocardiography. 2003.

  4. 19 14 32.13 ± 3.35 24.19 ± 8.6 20 1 10.9 4.6 21 34 25.69 ± 9.9 20.3 ± 9.08 21 9 18.64 ± 11.8 7.56 ± 4.4 23 20 21.72 ± 8.57 13.01 ± 5.27 22 1 23.0 25 5 16.46 ± 5.41 9.04 ± 2.27 23 84 13.55 ± 7.28 7.08 ± 4.33 27 1 19.2 ± 0 5.6 25 190 12.17 ± 5.75 6.2 ± 3.05 29 1 17.6 ± 0 11.6 27 240 9.96 ± 4.56 4.8 ± 2.33 29 200 7.91 ± 4.17 3.94 ± 2.15 Normal Values for Doppler Echocardiographic Assessment of Heart Valve Prostheses: aortic valveposition Carpentier-Edwards pericadial Stented bioprothesis Toronto stentless Porcine Stentless bioprothesis n. Pz gr. max. gr.med n. Pz gr. max. gr.med Rosenhek R. Journal of American Society of Echocardiography. 2003.

  5. 23 2 23 1 4.0 25 12 10.3 ± 2.3 3.6 ± 0.6 25 4 2.5 ± 1 27 78 8.79 ± 3.46 3.46 ± 1.03 27 16 11 ± 4 5 ± 1.82 29 46 8.78 ± 2.9 3.39 ± 0.97 29 40 10 ± 3 4.15 ± 1.8 31 57 8.87 ± 2.34 3.32 ± 0.87 31 41 12 ± 6 4.46 ± 2.22 33 33 8.8 ± 2.2 4.8 ± 2.5 27 16 6 ± 2 29 22 4.7 ± 2 31 22 4.4 ± 2 33 6 6 ± 3 Normal Values for Doppler Echocardiographic Assessment of Heart Valve Prostheses: mitral valveposition Carbomedics Bileaflet St Jude Medical Bleaflet Gradiente medio e di picco Carpentier-Edwards Stented bioprosthesis Rosenhek R. Journal of American Society of Echocardiography. 2003.

  6. TIPO di PATOLOGIA 1. MISMATCH 7. ENDOCARDITE 2. TROMBOSI Disfunzione protesica 6. DISTACCO 3. EMBOLIA 5. EMOLISI 4. STRUCTURAL FAILURE

  7. COME UTILIZZARE LE METODICHE SCOPIA TTE ETE Sospetto malfunzionamento ULTERIORI INFORMAZIONI ELEVATA SENSIBILITA’ E SPECIFICITA’ DIAGNOSTICA • protesi mitralica

  8. PROTESI MITRALICA How to do it SCANNERIZZARE la PROTESI da 0 a 120°

  9. How to do it VISUALIZZAZIONE MOVIMENTO DISCHI MISURAZIONE GRADIENTE VISUALIZZAZIONE TROMBI

  10. RISCONTRO di GRADIENTE ELEVATO in PROTESI AORTICA Pressure Recovery Disfunzione protesica Mismatch Fattori favorenti: - Anemia Febbre Tachicardia Alta portata Ostruzione sottovalvore residua

  11. PROBLEMA SPECIFICO per PROTESI AORTICHE.... Gradiente elevato Sintomi da sforzo MISMATCH Modificazioni prognostiche? Mancata regressione ipertrofia

  12. Patient Prosthesis Mismatch Indexed effective orifice area at rest (cm2/m2) EOAI= EOA\BSA Blais C.; Circulation 2003

  13. MISMATCH SCOPIA TT TE movimento gradiente . normale apertura dischi normale elevato . assenza di trombi The Am J Cardiol. 2000. Jan 1. Vol 85

  14. Impact of Valve Prosthesis-Patient Mismatch on Short-Term Mortality After Aortic Valve Replacement Variable P Risk Ratio (95% CI)‏ P Risk Ratio (95% CI)‏ Preoperative variables Previous myocardial infarction 0.03 2.2 (1.1-4.5)‏ … … Ventricular arhythmias 0.02 2.7 (1.2-6.0)‏ … … LV ejection fraction < 40% 0.002 3.7 (1.6-8.6)‏ 0.06 3.7 (1.5-0.4)‏ Operative variables Emergent/salvage operation 0.005 5.8 (1.7-19.6)‏ 0.047 4.5 (1.01-20.2)‏ Cardioput bypass time > 120 minutes 0.0003 3.9 (1.8-8.1)‏ 0.002 3.9 (1.6-9.3)‏ Severe PPM 0.004 5.5 (2.2-14.0)‏ 0.0003 7.2 (2.5-20.9)‏ Univariate analysis Multivariate analysis Predictors of Short-Term Mortality in Univariate and Multivariate analysys for the Subgroup of Patients with Moderate-Severe PPM (n=474)‏ Blais C. Circulation 26, 2003.

  15. Impact of Valve Prosthesis-Patient Mismatch on Short-Term Mortality After Aortic Valve Replacement LVEF < 40% LVEF ≥ 40% Mortality risk ratio Non significant Moderate Severe Valve prosthesis-patient mismatch Blais C. Circulation 26, 2003.

  16. Prosthesis-Patient Mismatch Affects Survival After Aortic Valve Replacement ID/BSA ≤ 10 mm/mq. 59 ±1% Overall Survival (%)‏ 28 ± 5% P = 0.03 1721 54 1386 39 959 19 585 6 336 2 1 2 3 4 5 6 7 8 9 10 Years Rao V. Circulation 2000. Nov 7; 102 (19 Suppl 3)‏

  17. Adjusted odd ratio 1.9 1.1 5.1 95% CI 0.7; 5.7 0.4; 2.9 1.5; 1.7 P Value 0.2 0.9 0.009 Prosthesis-patient mismatch after aortic valvereplacement predominantly affects patients with preexisting left ventricular dysfunction: Effect on survival, freedom from heart failure, and left ventricular mass regression 30.3% (12.1%)‏ Heart failure symptoms or death from heart failure by 3 years after aortic valve replacement 14.9% (3.2%)‏ Cumulative incidence (%)‏ 8.1% (4.6%)‏ 8.2% (1.9%)‏ Normal LV; No PPM Normal LV; PPM Impared LV; No PPM Impared LV; PPM “..Implantation of an aortic valve prosthesis with an estimated indexed EOA of 0.85 cmq/mq or less should be avoided in patients with a preoperative LVEF of less than 50%”. Ruel M .. J Thorac Cardiovasc Surg. 2006; May 131: (5) 1036-44

  18. COME EVITARE il MISMATCH ? 1. BSA x 0.85 = EOA minima (effective orifice area)‏ Normal Reference Value of effective Orifice Areas for the Prosthetic Valves Prosthetic Valve Size, mm

  19. OSTRUZIONE SOTTOVALVOLARE TT TE Ipertrofia SIV basale ASSE LUNGO Possibilità di accurata valutazione morfologica del SIV basale 4C PWD Gradiente a partenza sotto la protesi nell’LVOT

  20. OSTRUZIONE PROTESICA (trombo / panno)‏ Incidenza: 0.1-5% pz/anno . Fattori di rischio: .. scoagulazione inadeguata ... trombofilia ... Velocità del flusso TT SCOPIA TE GRADIENTE RIDOTTA APERTURA PRESENZA di ELEVATO del/i DISCO/I TROMBO

  21. PER la DIAGNOSI USARE: ECO + FLUOROSCOPIA . < MOVIMENTO DISCO . > GRADIENTE . < AREA DI FLUSSO: PHT>220 . RIGURGITO INTRA-PROT . VISUALIZZAZIONE TROMBO (TE)‏ SENS 87% SPEC 78% VP+ 80% SENS 75% SPEC 64% VP+ 57% • GRADIENTE< ESCURSIONE dei DISCHI ACC/AHA Guidelines 2003. Circulation 2003. September 9

  22. IMPIEGO SEMPLIFICATO dell’ECO TT per VALUTARE il FUNZIONAMENTO di una PROTESI MITRALICA Prosthetic Mitral Valve dysfunction? (n = 134)‏ E < 1.9 (n = 62)‏ E ≥ 1.9 (n = 72)‏ PHT < 130 (n= 58)‏ PHT ≥ 130 (n = 3)‏ PHT < 130 (n = 52)‏ PHT ≥ 130 (n = 20) Any Dysf 71% Regurg 69% Obstr 2% Any Dysf 71% Regurg 5% Obstr 9% Any Dysf 5% Regurg 5% Obstr 0% Any Dysf 100% Regurg 0% Obstr 100% PZ con E < 2 e PHT < 130 HANNO 95% di PROBABILITA’ di avere una PROTESI NORMOFUNZIONANTE Am J Cardiol 2002; 89:704-10

  23. ATTENZIONE al GRADIENTE !!!! DOPPIO DISCO SINGOLO DISCO Il blocco di un solo disco in alcuni casi non comporta un aumento del gradiente 30% 10% HANNO un GRADIENTE NORMALE delle TROMBOSI

  24. PROBABILITA’ DIAGNOSTICA TROMBO vs PANNO GRADIENTE ELEVATO MASSA MOBILE INSERZIONE sul DISCO INR < 2.5 TEE evaluation of suspected thrombus on pannus related MPVD N = 5 Elevated gradients Mobile mass Attachment to occluder INR ≤2.5 N = 18 N = 16 Prevalence (%)‏ N = 10 Predictors: 0-1 2 3-4 N = 4 Probability: Low Intermediate High 0 1 2 3 4 Risk factor(s)‏ Am Journ Cardiol. Vol 86. Nov 15. 2000

  25. 3. MORFOLOGIA / CARATTERISTICHE del TROMBO . < 5 mm. > 5 mm . NON OSTRUENTE. OSTRUENTE NON MOBILEMOBILE EPARINATROMBOLISI / CHIRURGIACHIRURGIA v. diapositive successive

  26. COMPLICANZE / MORTALITA’ e DIMENSIONI del TROMBO Complication Death 46.7 28.6 % 20 6.25 3.1 3.6 Thrombus <0.8 cmq 0.8-1.59 cmq ≥1.6 cmq Area No. of Patients 64 28 15 JACC Vol. 43. No 1. January 7, 2004: 77-84

  27. INDICAZIONI al TEE: DIAGNOSI nei CASI DUBBI D.D. fra TROMBO e PANNO trombo -> trombolisi panno -> intervento chirurgico 3. MORFOLOGIA/CARATTERISTICHE del TROMBO grosso e mobile -> no trombolisi; si chirurgia 4. EFFICACIA della TROMBOLISI scomparsa/riduzione delle dimensioni

  28. ALGORITMO di IMPIEGO DIAGNOSTICO ECO TEE Patients with suspected PVT (n = 82)‏ Cinefluoscopy – Transthoracic Echocardiography A CF+/TTE+ B CF+/TTE - C CF-/TTE+ D CF-/TTE- TEE not required if: - Bileaflet prosthesis in mitral position (aortic position?)‏ TEE not required if: - Aortic prosthesis, smal size (21,23) no symptoms TEE required if: - Mitral prosthesis, atrial fibrillation, systemic embolism TEE Not required: - In all cases • TEE required if: • Symptoms not explained by other cardiac or extracardiac source • mitral prosthesis? TEE required if: - Monocuspid valve (Lillehei-Kaster, Bicer prostheses)‏ TEE not required: - All other cases Am J Cardiol. Vol 85. Jan 1, 2000

  29. 2. DIAGNOSI DIFFERENZIALE: TROMBO vs PANNO CRITERIO TROMBO PANNO Tempo dall’impianto anche < 6 mesi > 6 mesi Durata dei sintomi breve (< 1 mese) lunga Scoagulazione inadeguata (2/3) adeguata Anomalo movimento disco frequente (up to 100%) + raro (up to 60%)‏ Morfologia massa larga, estesa in AS non estesa in AS omogenea disomogenea (calcif)‏ soft + ecoriflettente Movimento mobile/immobile solo immobile Localizzazione cerniera/disco anello

  30. ALGORITMO DECISIONALE ECO TT + SCOPIA ECO TE • Gradiente medio > 8 mm Hg • Ridotto movimento / blocco disco/i • Rigurgito intraprotesico • DD trombo / panno • Caratteristiche del trombo ALTO RISCHIO se: • trombo > 0.8 cmq > 1.6 cmq estensione extraprot. CHIRURGIA TROMBOLISI 1. TROMBO MOBILE 1. PZ ad ALTO RISCHIO CHIRURGICO 2. BLOCCO di 1 DISCO 2. DISCHI IPOMOBILI indip dalla durata > 21 gg e dalla classe NYHA 3. PANNO 3. BLOCCO di DISCO < 21 gg 4. BRIDGE alla CHIRURGIA

  31. Thrombosis of Prosthetic Heart Valves Class I Transtoracici and Doppler Echocardiography is indicated in patients with suspected prosthetic valve thrombosis to asses hemodynamic severity. (Level of Evidence: B)‏ Class I Transesophageal echocardiography and/or fluoroscopy is indicated in patietns with suspected valve thrombosis to asses valve motion and clot burden. (Level of Evidence: B)‏ ACC/AHA Guidelines 2006. JACC Vol 48 N 6.

  32. Panno

  33. 3. EMBOLIE PREVALENZA 1% pz/anno FATTORI di RISCHIO: • Protesi mitralica • Protesi multiple • Età > 70 anni • Fibrillazione atriale • Disfunzione ventricolare sx

  34. ENDOCARDITE PROTESI TROMBOSI PROTESI EMBOLIA INDICAZIONE a ECO TE TROMBOSI AURICOLARE CAUSE SCONOSCIUTE MALATTIA CAROTIDEA ATEROMA AORTA

  35. Detection of Prosthetic Valve Strands by Transesophageal Echocardiography: Clinical Significance in Patients With Suspected Cardiac Source of Embolism Valve Type CSE PVD/Misc P Value 19/125 (15%)‏ 0.0001 All mechanical (n=189)‏ 32/64 (50%)‏ 3/51 (6%)‏ 0.07 All bioprosthetic (n=59)‏ 2/8 (25%)‏ 15/60 (25%)‏ 0.0001 Mitral mechanical (n=95)‏ 23/35 (66%)‏ 2/32 (6%)‏ NS Mitral bioprosthetic (n=35)‏ 1/3 (33%)‏ 4/65 (6%)‏ 0.001 Aortic mechanical (n=94)‏ 9/29 (31%)‏ Aortic bioprosthetic (n=24)‏ 1/19 (5%)‏ NS 1/5 (20%)‏ Prevalence of Strands by Valve Type and Location Each Indication Indication for Study Orsinelli D. JACC. Dicember 1995. Vol 26. N 7: 1713-8

  36. Transesophageal Echocardiographic Findings in Patients With Nonobstructed Prosthetic Valves and Suspected Cardiac Source of Embolism TEE Findings Patients (n=52)‏ Prosthetic valve thrombus 6 (12%)‏ Periaortic graft thrombus 1 (2%)‏ Suspected thrombus/strands 5 (10%)‏ Protrunding nonmobile aortic atheroma 1 (2%)‏ Spontaneous echo contrast 12 (23%)‏ No abnormality 27 (52%)‏ MODIFICAZIONI TERAPEUTICHE in circa il 20% dei CASI Shiran A. Am J Cardiol. 2001. Dicember 15. Vol 86

  37. Patient’s Age (YR)‏ Percent with Valve Failure After 10 years < 40 42 40-49 30 50-59 21 60-69 15 ≥70 10 4. DEGENERAZIONE BIOPROTESI Circa 30% a 10-15 anni + frequente in: • Giovani (< 40 anni)‏ • Posizione mitralica Insorgenza graduale dei sintomi Heterograft valve failure 10 years after valve replacement according to the pateitn’s age at the time of implantation

  38. ECO STENOSI INSUFFICIENZA da: lesione o rottura di una o + cuspidi secondaria alla calcificazione

  39. 6. DISTACCO NON SETTICHE Errori nell’impianto Degenerazione/calcificazione anulus SETTICHE endocardite CAUSE:

  40. OBIETTIVI SEDE ESTENSIONE ENTITA’

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