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Transcript of Come riconoscere le disfunzioni protesiche Salvatore Felis.
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Come riconoscere le Come riconoscere le disfunzioni protesichedisfunzioni protesiche
Salvatore FelisSalvatore Felis
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TIPI di PROTESI
HancockCarpentier-
EdwardsIonescu-Shiley --------------
BioprostheticHeterograft
Homograft
Starr-EdwardsBjork-Shiley
Medtronic-HallOmnicarbon
St. Jude MedicalCarbomedics
Edwards-Duromedics
MechanicalCaged-ball
Single-tilting-disk
Bileaflet-tilting-disk
MODELTYPE
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Normal Values for Doppler Echocardiographic Assessment of Heart Valve Prostheses:
aortic valve position
Rosenhek R. Journal of American Society of Echocardiography. 2003.
8.41 ± 2.8319.05 ± 7.045727
12.68 ± 4.2926.31 ± 10.2511121
11.33 ± 3.824.61 ± 6.9312023
5.8 ± 3.212.53 ± 4.69629
9.34 ± 4.6520.25 ± 8.6910325
11.61 ± 5.0833.3 ± 11.196319
20.1 ± 7.133.4 ± 13.2717
Carbomedics Bileaflet
18.96 ± 6.27
35.17 ± 11.16
10019
15.82 ± 5.67
28.34 ± 9.94
20721
13.77 ± 5.33
25.28 ± 7.89
23623
10 ± 616.0 431
9.86 ± 2.917.72 ± 6.42
1829
11.18 ± 4.82
19.85 ± 7.55
8227
12.65 ± 5.14
22.57 ± 7.68
16925
St. Jude Medical Bileaflet
n. Pz gr. max. gr.med n. Pz gr. max. gr.med
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Normal Values for Doppler Echocardiographic Assessment of Heart Valve Prostheses:
aortic valve position
Rosenhek R. Journal of American Society of Echocardiography. 2003.
11.617.6 ± 0129
13.01 ± 5.2721.72 ± 8.572023
9.04 ± 2.2716.46 ± 5.41525
5.619.2 ± 0127
20.3 ± 9.0825.69 ± 9.93421
24.19 ± 8.632.13 ± 3.351419
Carpentier-Edwards pericadial Stented bioprothesis
4.6 10.9120
7.56 ± 4.418.64 ± 11.8
921
23.0122
3.94 ± 2.157.91 ± 4.1720029
4.8 ± 2.339.96 ± 4.5624027
6.2 ± 3.0512.17 ± 5.75
19025
7.08 ± 4.3313.55 ± 7.28
8423
Toronto stentless Porcine Stentless bioprothesis
n. Pz gr. max. gr.med n. Pz gr. max. gr.med
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Normal Values for Doppler Echocardiographic Assessment of Heart Valve Prostheses:
mitral valve position
Rosenhek R. Journal of American Society of Echocardiography. 2003.
4.8 ± 2.5 8.8 ± 2.233
33
3.46 ± 1.038.79 ± 3.4678
27 3.39 ± 0.978.78 ± 2.94
629 3.32 ± 0.878.87 ± 2.345
731
3.6 ± 0.610.3 ± 2.312
25
223
Carbomedics Bileaflet
4.0 123
2.5 ± 1425
5 ± 1.8211 ± 4
1627
4.46 ± 2.22
12 ± 64131
4.15 ± 1.810 ± 34029
St Jude Medical Bleaflet
6 ± 2 1627
4.7 ± 22229
6 ± 3633
4.4 ± 22231Carpentier-Edwards Stented bioprosthesis
Gradiente medio e di picco
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TIPO di PATOLOGIA
Disfunzione protesica
1. MISMATCH
2. TROMBOSI
3. EMBOLIA
4. STRUCTURAL FAILURE
5. EMOLISI
7. ENDOCARDITE
6. DISTACCO
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COME UTILIZZARE LE METODICHE
TTESCOPIA
ETE
ULTERIORI INFORMAZIONISospetto malfunzionamento
ELEVATA SENSIBILITA’ E SPECIFICITA’ DIAGNOSTICA
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PROTESI MITRALICA
SCANNERIZZARE la PROTESI da 0 a 120°
How to do it
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How to do it
VISUALIZZAZIONE MOVIMENTO DISCHI
VISUALIZZAZIONE TROMBI
MISURAZIONE GRADIENTE
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RISCONTRO di GRADIENTE ELEVATOin PROTESI AORTICA
Pressure Recovery
Mismatch
Ostruzione sottovalvore residua
Disfunzione protesica
Fattori favorenti:- Anemia Febbre Tachicardia Alta portata
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PROBLEMA SPECIFICO per PROTESI AORTICHE....
MISMATCH
Sintomi da sforzo
Mancata regressione ipertrofia
Modificazioni prognostiche?
Gradiente elevato
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Patient Prosthesis MismatchPatient Prosthesis MismatchIndexed effective orifice area at rest (cm2/m2) EOAI= EOA\BSA
Blais C.; Circulation 2003
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MISMATCH
movimento gradiente . normale apertura dischinormale elevato . assenza di trombi
SCOPIA TT TE
The Am J Cardiol. 2000. Jan 1. Vol 85
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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.
Impact of Valve Prosthesis-Patient Mismatch on Short-Term Mortality After Aortic Valve Replacement
7.2 (2.5-20.9)0.00035.5 (2.2-14.0)
0.004Severe PPM
3.9 (1.6-9.3)0.0023.9 (1.8-8.1)0.0003Cardioput bypass time > 120 minutes
4.5 (1.01-20.2)0.0475.8 (1.7-19.6)
0.005Emergent/salvage operation
Operative variables
3.7 (1.5-0.4)0.063.7 (1.6-8.6)0.002LV ejection fraction < 40%
……2.7 (1.2-6.0)0.02Ventricular arhythmias
……2.2 (1.1-4.5)0.03Previous myocardial infarction
Preoperative variables
Risk Ratio (95% CI)
PRisk Ratio (95% CI)
PVariable
Univariate analysis Multivariate analysis
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0
20
40
60
80
LVEF < 40%
LVEF ≥ 40%
Non significant
Moderate Severe
Mortality risk ratio
Valve prosthesis-patient mismatch
Blais C. Circulation 26, 2003.
Impact of Valve Prosthesis-Patient Mismatch on Short-Term Mortality After Aortic Valve Replacement
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Prosthesis-Patient Mismatch Affects Survival After Aortic Valve Replacement
ID/BSA ≤ 10 mm/mq.
0
20
40
60
80
100
Large
Small
Overall Survival (%)
1 2 3 4 5 6 7 8 9 10
1721
54
1386
39
959
19
585
6
336
2
59 ±1%
28 ± 5%
P = 0.03
YearsRao V. Circulation 2000. Nov 7; 102 (19 Suppl 3)
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0
10
20
30
40
Heart failure symptoms or death from heart failure by 3 years after aortic valve replacement
Normal LV;
No PPM
Normal LV;
PPM
Impared LV;
PPM
Cumulative incidence (%)
Ruel M .. J Thorac Cardiovasc Surg. 2006; May 131: (5) 1036-44
Prosthesis-patient mismatch after aortic valve replacement predominantly affects patients with preexisting left ventricular
dysfunction: Effect on survival, freedom from heart failure, and left ventricular mass regression
8.2%
(1.9%)
14.9%
(3.2%)
8.1%
(4.6%)
30.3%
(12.1%)
Impared LV;
No PPM
0.0090.90.2P Value
1.5; 1.7
0.4; 2.9
0.7; 5.795% CI
5.11.11.9Adjusted odd ratio
“..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%”.
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1. BSA x 0.85 = EOA minima (effective orifice area)
COME EVITARE il MISMATCH ?
No. of Patients, % 19 21 23 25 27 29 Ref erenceStented bioprosthetic valves
Medtronic I ntact 129 (10.2) 0,85 1,02 1,27 1,4 1,66 2,04 2Medtronic Mosaic 390 (30.8) 1,2 1,22 1,38 1,65 1,8 2 23
Hancock I I 53 (4,2) ... 1,18 1,33 1,46 1,55 1,6 4Carpentier-Edwards Perimount 59 (4,7) 1,1 1,3 1,5 1,8 1,8 ... 4
St. J ude Medical X-cell 21 (1,7) ... ... ... ... ... ... ...Stentless bioprosthetic valves
Medtronic f reestyle 368 (29.1) 1,15 1,35 1,48 2 2,32 ... 4St. J ude Medical Toronto SPV 60 (4,7) ... 1,3 1,5 1,7 2 2,5 4
Mechanical valvesSt J ude Medical standard 151 (11,9) 1,04 1,38 1,52 2,08 2,65 3,23 4St J ude Medical Regent 13 (1) 1,5 2 2,4 2,5 3,6 4,8 24
MCRI On-X 18 (1,4) 1,5 1,7 2 2,4 3,2 3,2 25Carbomedics 3 (0,2) 1 1,54 1,63 1,98 2,41 2,63 4
Bjork Shilley CC 1 0,1) ... ... ... ... ... ... ...
Prosthetic Valve Size, mm
Normal Reference Value of effective Orifice Areas for the Prosthetic Valves
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OSTRUZIONE SOTTOVALVOLARE
PWDGradiente apartenzasotto laprotesinell’LVOT
4C
ASSE LUNGOIpertrofiaSIVbasale
TT
Possibilità diaccurata valutazionemorfologica delSIV basale
TE
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OSTRUZIONE PROTESICA (trombo / panno)
GRADIENTE RIDOTTA APERTURA PRESENZA diELEVATO del/i DISCO/I TROMBO
TT SCOPIA TE
Incidenza: 0.1-5% pz/anno
. Fattori di rischio: .. scoagulazione inadeguata... trombofilia
... Velocità del flusso
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SENS 75% SPEC 64% VP+ 57%
SENS 87% SPEC 78% VP+ 80%
PER la DIAGNOSI USARE:
ECO + FLUOROSCOPIA
GRADIENTE < ESCURSIONE dei DISCHI
ACC/AHA Guidelines 2003. Circulation 2003. September 9
. < MOVIMENTO DISCO
. > GRADIENTE
. < AREA DI FLUSSO: PHT>220
. RIGURGITO INTRA-PROT
. VISUALIZZAZIONE TROMBO (TE)
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PZ con E < 2 e PHT < 130HANNO 95% di PROBABILITA’di avere una PROTESI NORMOFUNZIONANTE
IMPIEGO SEMPLIFICATO dell’ECO TT per VALUTARE il FUNZIONAMENTO di una PROTESI MITRALICA
Prosthetic Mitral Valve dysfunction? (n = 134)
Any Dysf 71%Regurg 69%Obstr 2%
PHT ≥ 130 (n =
20) PHT < 130 (n = 52)
PHT ≥ 130 (n = 3)
PHT < 130 (n= 58)
E ≥ 1.9 (n = 72)
E < 1.9 (n = 62)
Any Dysf 71%Regurg 5%Obstr 9%
Any Dysf 100%Regurg 0%Obstr 100%
Any Dysf 5%Regurg 5%Obstr 0%
Am J Cardiol 2002; 89:704-10
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30% 10%
HANNO un GRADIENTE NORMALE
ATTENZIONE al GRADIENTE !!!!
Il blocco di un solodisco in alcuni casinon comporta unaumento del gradiente
DOPPIO DISCO SINGOLO DISCO
delle TROMBOSI
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PROBABILITA’ DIAGNOSTICA TROMBO vs PANNO
1. GRADIENTE ELEVATO2. MASSA MOBILE3. INSERZIONE sul DISCO4. INR < 2.5
Am Journ Cardiol. Vol 86. Nov 15. 2000
0
25
50
75
100
0 1 2 3 4
Prevalence (%)
Risk factor(s)
TEE evaluation of suspected thrombus on pannus related MPVD
Elevated gradients
Mobile mass
Attachment to occluder
INR ≤2.5
Predictors:
Probability:
0-1 2 3-4
Low
Intermediate High
N = 4
N = 10
N = 16
N = 18
N = 5
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3. MORFOLOGIA / CARATTERISTICHE del TROMBO
. < 5 mm . > 5 mm
. NON OSTRUENTE . OSTRUENTE
EPARINA TROMBOLISI / CHIRURGIA CHIRURGIA v. diapositive successive
NON MOBILE MOBILE
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COMPLICANZE / MORTALITA’ e DIMENSIONI del TROMBO
0
20
40
60
80
100
JACC Vol. 43. No 1. January 7, 2004: 77-84
Thrombus <0.8 cmq 0.8-1.59 cmq ≥1.6 cmq
Area
No. of Patients 64 28 15
%
Complication
Death
6.253.1
28.6
3.6
46.7
20
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INDICAZIONI al TEE:
1. DIAGNOSI nei CASI DUBBI
1. 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
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ALGORITMO di IMPIEGO DIAGNOSTICO ECO TEE
Cinefluoscopy – Transthoracic Echocardiography
Am J Cardiol. Vol 85. Jan 1, 2000
Patients with suspected PVT (n = 82)
A
CF+/TTE+
B
CF+/TTE -
C
CF-/TTE+
D
CF-/TTE-
TEE
Not required:
- In all cases
TEE not required if:
- Bileaflet prosthesis in mitral position (aortic position?)
TEE required if:
- Monocuspid valve (Lillehei-Kaster, Bicer
prostheses)
TEE not required if:
- Aortic prosthesis, smal size (21,23) no symptoms
TEE required if:
-Symptoms not explained by other cardiac or extracardiac source
- mitral prosthesis?
TEE required if:
- Mitral prosthesis, atrial fibrillation, systemic embolism
TEE not required:
- All other cases
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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
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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
CHIRURGIA TROMBOLISI
1. TROMBO MOBILE 1. PZ ad ALTO RISCHIO CHIRURGICO2. BLOCCO di 1 DISCO 2. DISCHI IPOMOBILI indip dalla durata > 21 gg e dalla classe NYHA3. PANNO 3. BLOCCO di DISCO < 21 gg 4. BRIDGE alla CHIRURGIA
ALTO RISCHIO se:-trombo > 0.8 cmq > 1.6 cmqestensione extraprot.
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Thrombosis of Prosthetic Heart ValvesThrombosis 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.
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Panno
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3. EMBOLIE
PREVALENZA 1% pz/anno
FATTORI di RISCHIO:
-Protesi mitralica
-Protesi multiple
-Età > 70 anni
-Fibrillazione atriale
-Disfunzione ventricolare sx
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EMBOLIA
TROMBOSIPROTESI
ENDOCARDITEPROTESI
TROMBOSIAURICOLARE
ATEROMAAORTA
CAUSESCONOSCIUTE
MALATTIACAROTIDEA
INDICAZIONE a ECO TE
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Prevalence of Strands by Valve Type and Location Each Indication
NS1/19 (5%)1/5 (20%)Aortic bioprosthetic (n=24)
0.0014/65 (6%)9/29 (31%)Aortic mechanical (n=94)
NS2/32 (6%)1/3 (33%)Mitral bioprosthetic (n=35)
0.000115/60 (25%)23/35 (66%)Mitral mechanical (n=95)
0.073/51 (6%)2/8 (25%)All bioprosthetic (n=59)
0.000119/125 (15%)32/64 (50%)All mechanical (n=189)
P Value
PVD/MiscCSEValve Type
Detection of Prosthetic Valve Strands by Transesophageal Echocardiography: Clinical Significance in Patients With Suspected Cardiac Source of Embolism
Orsinelli D. JACC. Dicember 1995. Vol 26. N 7: 1713-8
Indication for Study
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MODIFICAZIONI TERAPEUTICHEin circa il 20% dei CASI
Transesophageal Echocardiographic Findings in Patients With Nonobstructed Prosthetic Valves and Suspected Cardiac Source of Embolism
Shiran A. Am J Cardiol. 2001. Dicember 15. Vol 86
27 (52%)No abnormality
12 (23%)Spontaneous echo contrast
1 (2%)Protrunding nonmobile aortic atheroma
5 (10%)Suspected thrombus/strands
1 (2%)Periaortic graft thrombus
6 (12%)Prosthetic valve thrombus
Patients (n=52)
TEE Findings
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4. DEGENERAZIONE BIOPROTESI
Circa 30% a 10-15 anni+ frequente in:-Giovani (< 40 anni)-Posizione mitralicaInsorgenza graduale dei sintomi
10≥70
1560-69
2150-59
3040-49
42< 40
Percent with Valve Failure After 10 years
Patient’s Age (YR)
Heterograft valve failure 10 years after valve replacement according to the pateitn’s age at the time of implantation
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ECO
INSUFFICIENZA da:lesione o rotturadi una o + cuspidisecondaria allacalcificazione
STENOSI
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6. DISTACCO
NON SETTICHEErrori nell’impiantoDegenerazione/calcificazione anulus
SETTICHEendocardite
CAUSE:
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1. SEDE
1. ESTENSIONE
1. ENTITA’
OBIETTIVI
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SEDE-ESTENSIONE
1 2 3 4 2 3 56 4
1
2
3
4
5
6
1 = antero-mediale4 = anteriore-medio5 = antero-laterale3 = postero-mediale6 = posteriore-medio2 = postero-laterale
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1. JET areaLIEVE = < 3 cmqMODERATO = 3-6 cmqSEVERO = > 6 cmq
2. PISALIEVE = < 0.5 cmMODERATO = 0.5-1 cmSEVERO = > 1 cm
3. VOLUME di RIGURGITOLIEVE = < 40 mlMODERATO = 40-60 mlSEVERO = > 60 ml
4. EROLIEVE = < 20 mm2
MODERATO = 20-40 mm2
SEVERO = > 40 mm2
4. FLUSSO VENOSO POLMLIEVE = S = DMODERATO = DOMINANZA DIASTOLICASEVERO = FLUSSO SISTOLICO INVERTITO
ENTITA’
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-ASSENZA di SCOMPENSO - SCOMPENSO-ASSENZA di EMOLISI - EMOLISI IMPORTANTE-LEAK PICCOLO - LEAK ESTESO-RIGURGITO LIEVE - RIGURGITO SEVERO
OSSERVAZIONE INTERVENTO
DECISION MAKING
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7. ENDOCARDITE
DATI:
1. In RIDUZIONE (oggi intorno all’1% entro il 1° anno)
1. MORTALITA’ ANCORA ELEVATA (25-65%)
ESTENSIONE LOCALE del PROCESSO
3. COLPISCE prevalentemente l’ANELLO e le STRUTTURE PERIANULARI
Ann Thorac Surg 2000; 69: 1388-92
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ENDOCARDITE
HOSPITAL COMMUNITYACQUIRED ACQUIRED(< 60 gg) (> 1 anno)
-RECRUDESCENZA CAUSE -REINFEZIONE-INFEZIONE PERI-OP -BATTERIEMIA(sala op, via centrale, cute etc..)
-Staf coag - AGENTE = a E. NATIVA-Funghi maggior % di-Staf aureus patogeni-Stp epid inusuali
-PEGGIORE PROGNOSI -MIGLIORE
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PECULIARITA’
1. FREQUENTE COINVOLGIMENTO
dell’ANELLO e delle STRUTTURE PERIANULARI
2. FLOW MASKING PROTESI
TE in AGGIUNTA al TT in OGNI CASO
448644Zabalgoitia et al. (1993) (bioprothesis)
368233Daniel et al. (1993)
171006Alton et al. (1992)
338312Taams et al. (1990)
TTE sensitivity (%)
TEE sensitivity (%)
No. Of patients
Sensitivity of TEE versus TTE in the diagnosis of prosthetic valve endocarditis
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TEE
VEGETAZIONI COMPLICANZE ENTITA’ PERI-ANULARI DISTACCO
ASCESSO PSEUDOANEURISMA FISTOLA
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ASCESSO FISTOLA
PSEUDOANEURISMA
Ridotta ecodensitàNon comunicanteAssenza di flusso
Cavità ben delineata
Idem ma comunicantePresenza di flusso
Comunicazione con flusso tra aorta ecavità cardiaca
DIAGNOSITEE
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FISTOLE
NC CD
AD VD
AS
CS
AD
VD
AS
Visualizzazione - Soluzione di continuo (2D) +- Jet turbolento (color)
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COSA COMPORTA laESTENSIONE PERIANULARE ?
1. MAGGIORE INCIDENZA di CHF
1. MAGGIORE MORTALITA’ in TM fino al 30-40%
3. PIU’ FREQUENTE RICORSO alla CHIRURGIA rr 3.2
1. INTERVENTO PIU’ COMPLESSO e di MAGGIORE DURATA
5. MAGGIORE MORBILITA’ e MORTALITA’ PERI-OP
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