Post on 04-Jun-2018
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Stenoza mitral
B. A. Popescu
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Obstacol la umplerea ventriculului stng
Stenoza mitral
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Etiologie Reumatismal (>95% cazuri) Calcificare de inel mitral Congenital
Lupus eritematos sistemic
Carcinoid
Artrita reumatoid
Hall RJC, Treasure T. In: Julian DG (ed.)Diseases of the heart, 1996:805.
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Fiziopatologie
Aria normal a orificiului mitral: 4-6 cm2
umplerea VS se face liber, fr gradient presional
n SM aria VM scade La arii VM
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Consecinele SM
HEMODINAMICE TROMBOEMBOLICE
PAS
PVP
PAP
Disfc VD
Dilatare AS
Fibrilaie
atrial
Tromb AS
Dispnee
EPA
Congestie sistemicEmbolism sistemic
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Simptomele:
sunt absente n SM larg
apar tardiv n evoluie
se instaleaz treptat
Anamneza
Apariia simptomelor este adesea provocat
de un factor declanator:
Debutul fibrilaiei atriale (ritm rapid) Infecie intercurent
Efort mare
Sarcin
Antecedente de RAA / faringite repetate
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Simptome
Simptome de congestie pulmonardispnee, tuse, hemoptizii
Simptome de congestie sistemic
Simptome de debit cardiac sczutfatigabilitate, ameeli
Simptome ale complicaiilor
palpitaii, embolii sistemice, febr Alte simptome
angin pectoral, rgueal (sdr. Ortner)
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Examenul fizic
Facies mitral (Dc sczut, RVP crescute,Sat O2 redus)
Unda a jugular ampl (HTP, ST asociat)
Semne de congestie sistemic (HTP)
oc apexian N / diminuat (n SM pur)
Zgomot 1 palpabil (valve pliabile)
Zgomot 2 palpabil la P (cnd exist HTP)
Freamt diastolic palpabil la apex
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Auscultaia
Manevre: decubit lateral stng
efort
Zgomot 1 ntrit (Z1) Clacment de deschidere a mitralei (CDM)
Uruitur diastolic (cel mai caracteristic semn)
ntrire presistolic a uruiturii
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Zgomot 1ntrit
Clacmentde deschidere
a mitralei
Hall RJC, Treasure T. In: Julian DG (ed.) Diseases of the heart, 1996:805.
Mecanismul Z1 i CDM
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Auscultaia: semne de severitate
Intervalul Z2-CDM: corelaie invers cu severitatea SMInterval scurt (
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Auscultaia n stenoza mitral
Z1 i CDM se auscult cel mai bine cu diafragmul stetoscopului
Uruitura se auscult cel mai bine cu plnia stetoscopului
Z1 ntrit
CDM
Uruitura
ntrirea
SM
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Diagnosticul diferenial auscultator
Z1 ntrit
CDM
Uruituradiastolicntrirepresistolic
Circulaie hiperkinetic
Stenoza tricuspidian
Pericardita constrictiv Mixom atrial
IA (Austin Flint) Stenoza tricuspidian Mixom atrial DSA (flux crescut)
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ElectrocardiogramaDilatarea AS:
Durata undei P > 0,12 sec (DII)
Componenta terminal a undei P ampl (V1)
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SM sever cu HTP
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Radiografia toracic
Semne indirecteDilatarea AS Bombare arc mijlociu stng (US)
Dublu contur (marginea dreapt)
Circulaia pulmonar
VS nedilatat (n SM pur) Arc inferior stng normal
Calcificri mitrale
Calcificri parietale AS
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Radiografia toracic
Semne indirecteDilatarea AS(mpinge/comprim
esofagul)
Dilatarea VD(umple spaiul
retrosternal)
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Ecocardiografia bidimensional
Pune diagnosticul de certitudine
VM normal SM strns
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Diagnosticul diferenial al cauzei
obstacolului mitral
SM valvular Mixom AS
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Principala metod pentru a evalua:
Extensia leziunilor anatomice Severitatea SM
Consecinele SM (AS, PAP, funcia VD)
ESC Guidelines on the management of valvular heart disease. EHJ 2007;28:230-68.
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Severitatea SM(cuantificare eco)
planimetrie(aria anatomic a VM)
gradieni AS-VS
pressure half-time (PHT)
(aria funcional a VM)
Doppler
Eco 2D
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Eco 2D: Planimetria
Msoar aria anatomic
Aria VM = 1,2 cm2
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Gradientul transmitral (eco Doppler)
Gradient mediu: 9,8 mm Hg
Flux normal Stenoz mitral
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Aria funcional Pressure half-time: timpul necesar pentru
ca gradientul iniial s scad la jumtate
t1/2
AVM [cm2] = 220/t1/2 [ms]
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Gradarea severitii SM
Gradient mediu
(mm Hg)
PAP sistolic
(mm Hg)
Aria valvei (cm2
)
< 5
< 30
> 1.5
5 - 10
30 - 50
1 - 1.5
> 10
> 50
< 1
Uoar Moderat Sever
ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart
Disease. Circulat ion 2006;114;84-231.
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Identificarea trombilor n AS / US
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Cnd este indicat cateterismul cardiac n SM?
Cnd testele neinvazive sunt neconcludente
Cnd exist discrepane ntre datele clinice i
cele furnizate de testele neinvazive
Cnd PAP este disproporionat de mare fa de
severitatea valvulopatiei
ESC Guidelines on the management of valvular heart disease. EHJ 2007;28:230-68.
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Esenialul pentru diagnosticul SM
Clinic
dispnee (de efort, DPN, ortopnee) fatigabilitate uruitura, CDM, Z1 ntrit
ECG
P mitral, FA, semne de HVD (std. tardiv)Rx
AS dilatat; VS normalEco
valve ngroate, deschidere redus, doming gradient crescut, arie VM sczut
Cateterism
rareori necesar, n cazuri selecionate
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Complicaiile SMHEMODINAMICE TROMBOEMBOLICE
PAS
PVP
PAP
Disfc VD
Dilatare AS
Fibrilaieatrial
Tromb AS
EPA
Congestie sistemicEmbolism sistemic
Insuficien cardiac
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Tratamentul stenozei mitrale
Nefarmacologic
Farmacologic Interventional
Chirurgical
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Tratamentul farmacologic
Obiective:
Combaterea tahicardiei
(ex: beta blocante, calciu blocante)Preventia trombembolismului
(anticoagulante orale)
Trat. insuficientei cardiace(ex: diuretice, vasodilatatoare IEC,
digoxin)
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Tratamentul interventional
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Tratamentul interventional
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Tratamentul interventional
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Tratament interventional
Succes arie peste 1,5cm2
Insucces 1-15%
Complicatii majore :mortalitate 0,5-4%hemopericard 0,5-10%embolism 0,5-5%
regurgitare severa 2-10%
Interventie chirurgicala de urgenta < 1%
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Tratament chirurgical
Indicat pentru pacientii cu stenoza mitralasemnificativa simptomatici, la care comisurotomiapercutana cu balon nu este o solutie (anatomiedefavorabila, regurgitare mitrala >usoara,
tromb intracavitar) sau cu necesar debypass aortocoronarian
Comisurotomie pe cord deschis (95% supravietuire la 15 ani)
Protezare mitrala
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Tratament chirurgical
Protezare mitralamortalitate 3-10% (varsta, clasa functionala, HTP,boala coronariana asociata)
Supravietuirea pe termen lungvarstaclasa functionalaFia
HTPFEVS preoperatorcomplicatiile protezei