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Valvulopatiile aortice

Valvulopatiile aortice. Dr. Roxana Cristina Rimbas. Insuficienta aortica. Definitie Etiologie Fiziopatologie Clinica Evaluarea bolnavului Indicatiile protezarii (inlocuirii valvulare) / chirurgia Tratamentul medical asociat. Definitie. Lipsa competentei valvei aortice

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Valvulopatiile aortice

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  1. Valvulopatiile aortice Dr. Roxana Cristina Rimbas

  2. Insuficienta aortica • Definitie • Etiologie • Fiziopatologie • Clinica • Evaluarea bolnavului • Indicatiile protezarii (inlocuirii valvulare) / chirurgia • Tratamentul medical asociat

  3. Definitie • Lipsa competentei valvei aortice • in timpul diastolei • Flux anormal din aorta retrograd in cavitatea VS • Forme • Acuta • Cronica • Patologie - valvulara - radacina aorta

  4. Etiologie I AO CRONICA • RAA • Degenerativa (asoc. cu St. Ao) • St Ao semnificativa + I Ao semnificativa = boala aortica • Endocardita infectioasa vindecata / persistenta • Congenitala – bicuspidia, monocuspidia aortica • Prolaps cuspa aortica (+/- prolaps v mitrala) • DSV cu prolaps cuspa aortica • Boli colagen vasculare • Spondilita ankilopoetica - cuspe aortice • Anomalii aorta ascendenta / Boala radacinii aortice - Dilatatie idiopatica • Asociata cu S. Marfan; necroza chistica a mediei • HTA necontrolata pe termen lung • Ectazia aortica senila • Aortita sifilitica, arterita cu celule gigante, Takayasu

  5. Etiologia I AO ACUTE • Disectie de aorta • Primara • Asociata cu alte patologii  s. Marfan • Endocardita infectioasa acuta • Rupturi valva aortica • Traumatica (accidente rutiere) • Ruperea unei cuspe • Prolaps v. aortica cu ruptura cuspei (rara)

  6. Fiziopatologie- I AO ACUTA - Soc cardiogen Creste pres retro ↑↑↑ VS mic, hiperkinetic Presarcina ↑↑↑ PTD VS ↑↑↑

  7. Fiziopatologie- I AO CRONICA - Creste volumul bataie = efectiv + regurgitat Crestere gradata PTDVS DC mentinut Dilatare VS FEVS N/↑ HVS excentrica – VS compliant, Crestere masa miocardica Ischemie miocardica VS hiperkinetic

  8. Fiziopatologie- I AO CRONICA: decompensarea- Afectare tardiva de cord drept Insuf mitrala secundara DC scade Creste pres retro ↑↑↑ Dilatare severa VS PTD VS ↑↑↑ Scadere progresiva FEVS

  9. Clinica- I AO ACUTA - • SOC CARDIOGEN !!! • Pacient grav • hipoTA severa, vasocontrictie periferica, cianoza • EPA cardiogen +/- asociat ATENTIE!!! Semnele clasice de I Ao CRONICA severa absente !!! • Suflu diastolic (daca exista e scurt!) • Puls saltaret • Soc apexian amplu

  10. Clinica- I AO cronica - • Indelungat asimptomatica • Pacientii tolereaza efortul excelent pana in fazele avansate (de decompensare) • Decompensarea = simptome • Dispnee de efort  DPN • Angina pectorala(HVS excentrica, diastola redusa) • Palpitatii (resimt sistola viguroasa) • Moarte subita

  11. Examen obiectiv- I AO cronica - • Inspectie – semne secundare Pres diferentiala crescuta • Pulsatii ample carotidiene • Puls saltaret – depresibil (Water – hammer / Corrigan) • Impulsuri sistolice ale capului (Musset), uvulei (Muller) • Traube (zgomote de tun pe a femurale) • SS + SD a femurale (Duroiziez) • Pulsatilitate capilara (Quincke) • TA diferentiala crescuta cu TAd redusa semnificativ (<60mmHg)

  12. Examen obiectiv- I AO cronica - • Examen cord • Cardiomegalie (cele mai mari volume!!!) • SD dulce aspirativ, fin, <3/6, focar Erb, descrescendo. Durata scurta = severitate • SS de debit, ejectional • S3 galop – disfunctie VS • SD de uruitura mitrala = Austin Flint= severitate • Fara clacment, fara intarire Z1 • Examen general – semne de insuficienta cardiaca stanga sau dreapta = severitate

  13. Evaluarea paraclinica • ECG (I Ao cronica!) • HVS cu pattern suprasolicitare volum • Q derivatii laterale (D1, aVL, V4-V6) • Strain VS • HAS • Aritmii a/v • RxCP (I Ao cronica!) • Dilatare VS (arc inferior stang), uneori extrema • Dilatare aorta ascendenta

  14. Evaluarea paraclinica • ECOCARDIOGRAFIA = de electie! • Severitate • Etiologia I aortice • Volum VS • Functie VS • Leziuni valvulare asociate • Indicatie operatorie • monitorizare

  15. Criterii de severitate eco • Elemente semicantitative • Jet regurgitant ocupa > 65% tract ejectie VS • Diametrul minim al convergentei jet (v.c.) > 6mm • Volum regurgitant > 60ml • Arie orificiu regurgitant > 0.3 cm2 • Reflux holodiastolic in aorta descendenta • Dilatare moderata sau mare VS

  16. Evaluarea paraclinica • Rezonanta magnetica • Indicatii: pacienti cu evaluare eco suboptimala • Cea mai performanta metoda de evaluare a • Volume VS • Masa VS • Arie orificiu regurgitant aortic • Volum regurgitant • Coronarografie preoperatorie • Angiografie aortica pentru evaluare I aortica (rar)

  17. Urmarire pacient • Ecocardiografie • I AO usoara: 2-3 ani • I AO medie: anual • I AO severa asimptomatica: 6 luni

  18. Tratament • I Aortica acuta • CHIRURGIE DE URGENTA • Tratament medical suportiv • Inotrop pozitive (dobutamina / dopamina) • Daca TA > 90 mmHg si congestie pulmonara: cu atentie furosemid • NICIODATA • Betablocante • Balon contrapulsatie aortica

  19. Tratament- I aortica cronica - • Medical • Indicatii • Pacienti care NU intrunesc indicatii operatorii • Pacienti depasiti operator • Ce medicatie? • Vasodilatator periferic • Ca-blocante DHP (Amlodipina, Nifedipin retard, etc) • IECA • Control retentie hidrosalina • Furosemid +/- spironolactona • B blocante – IAo din Marfan mai ales/ IAo cu insuf. cardiaca cronica • Profilaxia EI

  20. Tratamentul de electie: protezare valvulara • Indicatii: • I AO SEVERA + simptome (ICC sau angina) • I AO SEVERA + asimptomatici care au • FEVS < 50% (ATENTIE, e foarte scazuta in IAo) • FEVS › 50% • Diam teleD VS > 70mm • Diam teleS VS > 50mm (sau 25mm / m2) • I Ao semnificativa daca chirurgie alta valva/CABG / aorta • Dilatare aorta ascendenta asociata cu I Ao orice grad: • 45 mm s. Marfan; 50mm bicuspidie aortica; 55mm alte etiologii

  21. Proteze valvulare metalice

  22. Proteze biologice

  23. Concluzii • Doar 50% sunt degenerative. Restul de 50% apartin celorlalte etiologii • Simptome = severitate = operatie • Evaluarea = ecocardiografica • Severitate • monitorizare • Tratament de electie = protezare valvulara

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