Protezele Valvulare Cardiace Diagnostic .tratament: Curs Rezidenti 2018

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Protezele valvulare cardiace Diagnostic .Tratament

Curs rezidenti 2018

Introducere CCV -Protezarea valvulara cardiaca-1960  >100 milioane de pacienti cu valvulopatii in lume  4 milioane de proteze valvulare in ultimii 50 de ani  Se vor implanta 850.000/an pana in 2050  Patologia valvulara --- patologia protezelor valvulare  Evolutia pacientului protezat depinde de - tipul protezei –profilul hemodinamic - durabilitate - trombogenicitate - complicatiile pot fi prevenite prin alegerea optima a protezei , controale periodice 

Figure 1. Different types of prosthetic valves.

Different types of prosthetic valves. A, Bileaflet mechanical valve (St Jude); B, monoleaflet mechanical valve (Medtronic Hall); C, caged ball valve (StarrEdwards); D, stented porcine bioprosthesis (Medtronic Mosaic); E, stented pericardial bioprosthesis (Carpentier-Edwards Magna); F, stentless porcine bioprosthesis (Medtronic Freestyle); G, percutaneous bioprosthesis expanded over a balloon (Edwards Sapien); H, self-expandable percutaneous bioprosthesis (CoreValve). Philippe Pibarot, and Jean G. Dumesnil Circulation. 2009;119:1034-1048 Copyright © American Heart Association, Inc. All rights reserved.

Proteze valvulare cardiace mecanice

• mai durabile decât cele biologice • trombogenice

anticoagulare sistemică

• preferate la pacienţi tineri

Proteze mecanice cu 2 hemidiscuri (St. Jude, Carbomedics) TEE - proteză mitrală: - mobilitatea hemidiscurilor - închiderea (300) / deschiderea –

simetrică (85-900) - incidenţa optimă de examinare ME

TEE - proteză aortică: - mobilitatea hemidiscurilor – dificilă • cele mai frecvent implantate

dat. umbrei acustice dată de inelul

• durabilitate crescută

protezei

• arie efectivă a orificiului protetic mare

- incidenţa optimă de examinare TG

Proteze biologice 



 



Tesut uman (homograft) –allograft - autograft Tesut animal (xenograft) –valva aortica porcina - pericard bovin Stent /stentless Inele valvulare Valve percutan /clipuri

Proteze valvulare cardiace  



 

Valve percutan -tesut pericardic fixat pe un stent metalic expandabil /stent de nitinol autoexpandabil (Edwards Sapien, Core Valve) Protezele homograft -- tesut valvular uman crioprezervat de la donatori Proteze pulmonare autograft - transferul valvei pulmonare proprii - pozitie Ao si reprezinta <1% din protezele Ao Protezele homograft nu sunt superioare bioprotezelor din pericard datorita deteriorarii structurale in timp, mai ales la pacienti tineri (11 vs 25 ani ) Singura indicatie !!! a homograft ramine EI cu leziuni perivalvulare Procedura Ross de implantare a valvei pulmonare in pozitie Ao –rezultate f bune dar exista doua probleme : - stenoza precoce a homograft pulmonar - reaparitia IAo datorita dilatarii in continuare a radacinii Ao

Proteze biologice Avantaje: - nu necesită anticoagulare - imagine ultrasonografică de calitate

(Carpentier -

Dezavantaje: - durabilitate limitată (12-15 ani) - se implantează la:  vârstnici  intoleranţă la ATC - aria efectivă < proteze cu 2 hd

Edwards Perimount

Proteze biologice stentless Avantaje:

(St. Jude Toronto) – “Stentless”

- Profil hemodinamic foarte bun - Aria efectivă a orificiului mare, prin eliminarea stenturilor - Se implantează mai ales la cei cu Aoi sub 20 mm - Mobilitate superioară a cuspelor – longevitate crescută - TEE – aspect asemănător cu al valvei aortice native - Creşterea grosimii peretelui aortic în zona suprapunerii cu valva

Dezavantaje: - Mismatch-ul proteză / rădăcină Ao leakuri paravalvulare IAo (25%)

Evaluarea protezelor valvulare ascultatie normala 



Valve mecanice : -zgomot de inchidere sonor metalic de frecventa inalta -zgomot de deschidere de intensitate redusa fin (tilting disc / bileaflet valves) Valve biologice :ascultatie similara cu valvele native

Evaluarea protezelor valvulare ascultatie normala 



Protezele Ao : datorita obstructiei in LVOT – suflu sistolic de ejectie ; suflu diastolic de intensitate redusa (tilting disc si bileaflet valves) Protezele Mi :suflu diastolic scurt (bioprostheses si rar la St. Jude bileaflet valves)

Semne si simptome – malfunctie de proteza  







 

Depinde de tipul valvei si de localizare Insuficienta valvulara protetica acuta : dispnee brusc instalata, sincopa, durere precordiala Insuficienta aortica acuta : MS, dispnee acuta severa , durere precordiala, sincopa Insuficienta valvulara subac: agravarea treptata a simpt de ICC; angina instabila ,asimptomatic Complicatii embolice : AVC,IMA,MSC,ischemie periferica sau viscerala Hemoragie –dependenta de terapia anticoagulanta Istoric de febra –EI pe proteza

Insuficienta acuta de proteza      

 

Perfuzie tisulara scazuta Puls periferic diminuat /absent Tegumente reci transpirate Debit urinar redus/absent Stare confuzionala/ neresponsiv Absenta zgomotului de inchidere al protezei sau diminuarea lui Impuls precordial hiperdinamic (50% dat de VD) Suflu de regurgitare patologic

Insuficienta subacuta de proteza  

  

Semne de IC dreapta Raluri pulmonare , distensie vena jugulara hepatomegalie,edeme Suflu de regurgitare nou aparut Zgomot de inchidere redus sau normal Anemie hemolitica nou dg sau agravata

Manifestari in EI PV   

 



Febra in 96% din cazuri Suflu nou aparut 56% Manifestari generale :petesii,pete Roth,noduli Osler,leziuni Janeway -rare Splenomegalie 26% ICC,soc septic ,Insuf valvulara ac prin dehiscenta protezei Embolii sistemice in 7-33%

Complicatii trombembolice   

AVC cel mai frecvent IMA,MSC Ischemie periferica sau de organ

Alegerea tipului de proteza implantata

Alegerea tipului de proteza implantata (50-70 ani ) Several studies have shown a survival advantage with a mechanical prosthesis in this age group (142,157-159). Alternatively, large retrospective observational studies have shown similar long-term survival in patients 50 to 69 years of age undergoing mechanical versus bioprosthetic valve replacement (143-145,160). In general, patients with mechanical valve replacement experience a higher risk of bleeding due to anticoagulation, whereas individuals who receive a bioprosthetic valve replacement experience a higher rate of reoperation due to structural deterioration of the prosthesis and perhaps a decrease in survival (142,143,145-160,162). Stroke rate appears to be similar in patients undergoing either mechanical or bioprosthetic AVR, but it is higher with mechanical than with bioprosthetic MVR (142-145,157).

Evaluarea protezelor valvulare 



 



Laborator – hemoleucograma,uree,creatinina hemoculturi,LDH,coagulograma(INR,APTT) Cinefluoroscopia – tipul protezei,integritatea ocluder,miscarea discului/discurilor ETT,ETE metoda de electie in dg malfunctiilor CT –TAVI ,EI periprotetica ETE 3D

ETT Parametrii 2D care urmaresc structura valvei -miscarea discului,ocluderului,foitelor valvulare -prezenta calcificarilor,a formatiunilor atasate de proteza -integritatea inelului,mobilitatea  Parametrii Doppler care reflecta functia valvei -conturul anvelopei Doppler -velocitatea max,grd max,mediu ,VTI -indexul velocitatilor (proximal si pe proteza) -PHT (Mi,Tri) -Aria efectiva a orificiului protetic -severitatea regurgitarilor, -dimensiunile cavitatilor, -HTP 

OBSTRUCTIA CRITERII TTE, TEE

Tratamentul antitrombotic 





Toti p cu valve mecanice si cei cu valve biologice care au alta indicatie de anticoagulant – vor primi ATC toata viata P cu proteze biologice –primele 3 luni dupa protezare INR (International Normalized Ratio = timpul de protrombina al bolnavului/ t de protrombina normal)-optim va diferi in fctie de proteza si de factorii de risc

Tratamentul antitrombotic Factori de risc : -protezarea Mi ,Tri, P -antecedente de TEP -Fia ,SM,AS>50,contrast spontan dens,FE<35% -stare de Hcoagulabilitate -Trombogenicitatea este mai mare la protezele mitrale fata de aortice -ATC trebuie inceputa imediat postop -ATC cronica la protezele mi – singerare minora 2-4%,singerare majora 1-2%/an Riscul sangerarilor creste cand INR>4,5 -INR >6 spitalizare ,oprirea ATC ,nu vitamina K iv !!! (vitamina K oral la cei care au primit antivitamine K cu durata lunga de actiune fenoprocumon ) -INR>10 plasma proaspata -daca bolnavul sangereaza va fi tratat cu plasma proaspata si vit K iv 

Tratamentul antitrombotic 





ATC cu AVK – INR 2,5 se recomanda protezelor mec Ao (bileaflet or currentgeneration single tilting disc) ATC cu AVK -- INR 3.0 se recomanda protezelor mec Ao cu f de risc (AF, previous thromboembolism, LV dysfunction, or hypercoagulable conditions) sau proteze mec de generatie veche ( as ball-in-cage)(564). (Level of Evidence: B) fara factori de risc pt tromboembolism(561–563). (Level of Evidence: B) ATC cu AVK -- INR 3.0 se recomanda protezelor mec Mi (564,565). (Level of

Evidence: B) 

Aspirin 75 mg - 100 mg /zi se recomanda pe langa ATC protezelor mecanice

(Level of Evidence: A)

Tratamentul antitrombotic Many patients who undergo implantation of a surgical bioprosthetic MVR or AVR will not require life-long anticoagulation. However, there is an increased risk of ischemic stroke early after operation, particularly in the first 90 to 180 days after operation with either a bioprosthetic AVR or MVR (198-205). Anticoagulation early after valve implantation is intended to decrease the risk of thromboembolism until the prosthetic valve is fully endothelialized. The potential benefit of anticoagulation therapy must be weighed against the risk of bleeding. In a nonrandomized study, patients with a bioprosthetic MVR who received anticoagulation had a lower rate of thromboembolism than those who did not receive therapy with VKA (2.5% per year with anticoagulation versus 3.9% per year without anticoagulation; p=0.05) (193).

Tratamentul antiagregant 









Aspirina 100 mg /zi pe langa anticoagularea orala AVK scade incidenta emboliilor majore sau decesului (1.9% versus 8.5% per year; p<0.001), cu scaderea ratei AVC la 1.3% versus 4.2% /an (p<0.027) si mortalitatea de toate cauzele la 2.8% vs 7.4% /an (p<0.01) Aspirina (75 mg to 100 mg/zi ) pe langa anticoagularea orala AVK (INR 2.0 to 3.5) scade mortalitatea datorata altor boli cardiovascular e Combinatia de doza redusa de aspirina si AVK se asociaza cu cresterea usoara a riscului de hemoragii minore ( epistaxis, hematuria) insa riscul de hemoragii majore nu difera semnificativ (8.5% versus 6.6%; p=0.43). Riscul iritatiei GI si hemoragiei cu aspirina este dependent de doza peste 100 mg -1,000 mg /zi, insa efectul antiplachetar este independent de doza peste aceasta limita Aspirina (75 mg to 100 mg /zi ) pe langa AVK este recomandata cu exceptia CI (hemoragie sau intoleranta la aspirina). Combinatia se recomanda in special p.lor antecedente de emboli sub AVK cu INR terapeutic,celor cu boala vasculara cunoscuta cu status hipercoagulant

Tratamentul“bridging “ 





Continuarea ATC cu AVK cu INR terapeutic se recomanda p.lor cu proteze mecanice care urmeaza proceduri minore (extractii dentare ,op cataracta) unde sangerarea este usor de controlat (Level of Evidence: C) Interuperea temporara a AVK fara suprapunere cu alte ATC chiar daca INR este subterapeutic, se recomanda p.lor cu valve mec Ao bileaflet si fara alti factori de risc pt tromboza care sunt supusi procedurilor invazive sau chirurgicale (Level of Evidence: C) . Administrarea de plasma proaspata sau complex de prothrombina concentrate se accepta la p cu valve mecanice sub ATC cu AVK si care necesita chirurgie de urgenta noncardiaca sau proceduri invazive (Level of Evidence: C)

Tratamentul antitrombotic

Tratamentul“bridging “ 

When interruption of oral VKA therapy is deemed necessary, the agent is usually stopped 3 to 4 days before the procedure (so the INR falls to <1,5 for major surgical procedures) and is restarted postoperatively as soon as bleeding risk allows, typically 12 to 24 hours after surgery. Bridging anticoagulation with intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin is started when the INR falls below the therapeutic threshold (i.e., 2.0 or 2.5, depending on the clinical context), usually 36 to 48 hours before surgery, and is stopped 4 to 6 hours (for intravenous unfractionated heparin) or 12 hours (for subcutaneous low-molecular-weight heparin) before the procedure.

Complicatiile protezelor valvulare

Philippe Pibarot, and Jean G. Dumesnil Circulation. 2009;119:1034-1048 Copyright © American Heart Association, Inc. All rights reserved.

TIPURI DE DISFUNCTII DE PROTEZA : 1. Obstructie -tromboza: 0,1-5,7% /pacient-an †↑ -panus: 0,2% -mismatch sever (obstructie relativa/Sc): 2-10%

2. Regurgitare -leakuri paravalv mod/sever: 1-2%

3. Infectie -endocardita: 2-4%

†↑

4. Degenerare –p. bio: 3-4%/5ani

35%/15ani

DIAGNOSTICUL DISFUNCTIILOR DE PROTEZA : TTE, TEE 1. Obstructie - TTE, TEE - velocitate maxima - gradient mediu - aria orif protetic - indice de permeabilitate=VTI LVOT,VTIproteza - forma anvelopei proteze - timp de accelerare aortice 2. Regurgitare - TTE, TEE - flux color - crestere gradient cu indice de permeabilitate N - miscarea de balans a protezei 3. Infectie - TTE, TEE - vegetatii - abces criteriile Duke - dehiscenta 4. Degenerare -TTE, TEE - regurgitare - stenoza

Tratamentul trombozei de proteza valvulara The overall 30-day mortality rate with surgery is 10% to 15%, with a lower mortality rate of <5% in patients with NYHA class I/II symptoms (225,226,232-234). The results of fibrinolytic therapy before 2013 showed an overall 30-day mortality rate of 7% and hemodynamic success rate of 75% but a thromboembolism rate of 13% and major bleeding rate of 6% (intracerebral hemorrhage, 3%) (224-230). However, recent reports using an echocardiogram-guided slow-infusion low-dose fibrinolytic protocol have shown success rates >90%, with embolic event rates <2% and major bleeding rates <2% (231,235). This fibrinolytic therapy regimen can be successful even in patients with advanced NYHA class and larger-sized thrombi. On the basis of these findings, the writing group recommends urgent initial therapy for prosthetic mechanical valve thrombosis resulting in symptomatic obstruction, but the decision for surgery versus fibrinolysis is dependent on individual patient characteristics that would support the recommendation of one treatment over the other, as shown in Table 4, as well as the experience and capabilities of the institution. All factors must be taken into consideration in a decision about therapy, and the decisionmaking process shared between the caregiver and patient. Final definitive plans should be based on the initial response to therapy.

Chirurgie/fibrinoliza

ve Algorithm for the management of patients with prosthetic valve thrombosis

Tromboza de proteza mecanica mitrala

Tromboza de proteza mecanica Mitrala

Tromboza de proteza mecanica mitrala 

mobilitate



ecogenitate 



Hipoecogenitatea corelaţie pozitivă semnificativă statistic accidentele embolice Hiperecogenitatea

Caracteristicile ETE ale TVP care au crescut riscul embolic 

mobilitate 



39 TVP Mi: 15(38%) m↑: 53% AIT, AVC

ecogenitate 



Hipoecogenitatea corelaţie pozitivă semnificativă statistic (p=0.0009) cu accidentele embolice Hiperecogenitatea

Reinterventie chirurgicala Disfunctie mod/severa,structurala/nonstruct  Dehiscenta de proteza  EI P Cauze de stenoza : -proteze mecanice :tromboza acuta ,tromboza veche,pannus care impiedeca miscarea discului -proteze biologice : fibroza,calcefiere  Tromboembolism recurent  Hemoliza ivasculara severa  Hemoragie severa recurenta (ATC) Regurgitarea valvulara protetica bioproteze –ETT apreciaza calcificarea/degenerarea foitelor , severitatea hemodinamica,fctia VS, grd HTP(Vmax,grd max,med) Proteze mecanice – ETE-Mi –regurgitare paravalvulara datorata panus/tromboza veche –inchidere percutana 

Mismatch proteza –pacient Marimea protezei –flux inadecvat raportat la aria suprafetei corporale ,chiar daca proteza e normofunctionala  AEOP indexata<= 0,85 cm2/m2-proteza Ao - predictor de grd protetic crescut - HVS - evenimente cardiace ulterioare  AEOP indexata <=0,65 cm2/m2 –mismatch sever (FE<)  -alegerea protezei cu AEOP adecvata BSA  -largirea chirurgicala a inelului Ao 

Algorithm for the interpretation of high transprosthetic gradient. IEOA indicates indexed EOA. gh transprosthetic gradient.

Philippe Pibarot, and Jean G. Dumesnil Circulation. 2009;119:1034-1048 Copyright © American Heart Association, Inc. All rights reserved.

Proteze valvulare cardiace la gravide 

 

 



ETT pt evaluarea protezei inainte de sarcina pt a decela disfunctia de proteza ,care se poate agrava in cursul sarcinii (stenoza,regurgitare,tromboza,mismatch ) Status hipercoagulant – risc de tromboza de proteza Grd transprotetic creste in primele 2 trim de sarcina fiziologic datorita >DC PHT,DVI ETT repetata daca se modifica tb clinic (bioprotezele devin stenotice in timp, insa regurgitarile se pot produce acut prin desprinderea inelului din zona cu calcificare ) ETE dg tromboza de proteza mec /ev embolic

Proteze valvulare cardiace la gravide

Proteze valvulare cardiace la gravide 

  





Toate ATC cresc riscul de anomalii fetale,avort,complicatii hemoragice nastere prematura In abs ATC mortalitatea materna 5%,riscul de tromboza 24% Warfarina efect teratogen in primul trim de sarcina Riscul ev trombembolice sub warfarina in sarcina <4% vs 33% sub UFH LMWH –risc de tromboza protetica redus fata de UH daca se monitorizeaza ef antiX Risc de embriopatii in primul trim 8% - Warfarina >5 mg se prefera LMWH vs UH embriopatii 3% -Warfarina <5 mg/zi

Radioscopie/Radiografie toracică în urgenţa

• Edem interstiţial • HTP venoasă mare • HTP rezistenţă moderată • ICT mărit: VS > II, AS > II, ID > AD, VD • Proteză mecanică Mi cu deschidere normală, închidere incompletă

Ecocardiografie transesofagiană în urgenţă

Tromboliză de urgenţă cu SK Bolus: 500.000 U  3.000.000 / 24 h; apoi 100.000 / h sub controlul fibrinogenului la 4 h; fibrinogen: 35 mg/dl  întrerupt temporar Tratament: Furosemid, diluţie Mo PrePostEvoluţie clinică mult ameliorată ! tromboliză tromboliză

Eco transesofagian control

Radioscopie de control • Mişcarea discului protezei cu amplitudinea de deschidere / închidere normală • HTP venoasă uşoară

Radiografie de control

Externat - ameliorat • Tratament anticoagulant cu menţinerea INR 3,5 – 4 ! • Tratament antiagregant plachetar Aspirină • Profilaxia endocarditei bacteriene

Reinternare TEE

Acelaşi tablou clinic – dispnee la eforturi minime, ortopnee VSH = 20 mm/h, L = 9800 x103/μl, F = 560 mg/dl

INR = 1,8 !

Tratament chirurgical • Intraoperator, se evidenţiază trombi vechi pe inel şi pe discul protezei • Rezecţia protezei, cu montarea unei proteze biologice

• Plastie tricuspidiană

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