Prezentare de Caz -1
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Prezentare de caz
Grupa 27Tivadar Beatrice
Nastasel ValentinaSasu Andreea
Zikovska Vanessa
Sef de lucrari: Dr. Vatasescu Radu
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Pacient: I.N.Sex: MasculinVarsta: 57 ani
Factori risc cardiovascular:
• Dislipidemie• Hipertensiune • Obezitate
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Motivele internarii-Palpitatii
•Astenie•Greata•Varsaturi
Istoricul bolii•Anterior internarii, pacientul acuza palpitatii cu ritm regulat, de scurta durata, autolimitante.
•Greata si vasaturi cu dureri abdominale difuze – sdr dispeptic
•La prezentare: distress acut, hipotensiune,
•AHC: moarte subita
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Examen obiectiv •Stare generala medie, hipotensiune (80/60 mmHg);
•Matitate cardiaca marita (8-9cm2)
•Soc apexian deplasat pe linia axilara anterioara in spatiul 6 intercostal stang
•Auscultatie: zgomote cardiace cu ritm rapid, suflu de grad I audibil in focarul mitral fara iradiere
•POSTCONVERSIE: repeta palpitatiile aparent cu trigger PS, la repaus, la Spitalul Clinic de Urgenta Bucuresti.
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Analize laborator
AST 635 U/lALT 2230 U/lUree 48.90 mg/dlCK MB 30 U/lCreatinina 1.4 U/lAmilaza 170 U/lLDH 1718 U/lSodiu 141.45 mmol/lPotasiu 3.23 mmol/l
Valorile sunt concordante cu simptomatologia digestiva sugerand un sindrom dispeptic (pancreatita acuta).
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La internare S.C.U.B.
•Stare generala relativ buna
•Fara simptomatologie digestiva
•Reapare tahicardia care de aceasta data este bine tolerata
• Nu raspunde la tratamentul cu lidocaina si sulfat de magneziu => conversie electrica
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Tratament
Acid acetilsalicilic 75 mg 1 cp/ziClopidogrel 75 mg 1 cp/ziBetaloc 50 mg 1 cp x3/zi titrare progresivaZofenopril 7,5 mg 1 cp/ziAtorvastatina 80 mg 1 cp/zi
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Episod de TV monomorfa sustinuta • TV cu frecv. de 200 bpm, ax inferior - in DII, DIII, aVF, complexe QRS monomorfe, largi, cu durata >160 msec, cu aspect BRS-like;• disociere A-V observabila in V1.
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EKG post-conversie• ritm sinusal, FC: 75 bpm, AQRS~0°, unda Q pozitionala in DIII, subdenivelari difuze de segm. ST in DI, DII, aVL, V4-V6, supradeniv. de segm ST in aVR.
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EKG de baza• ritm sinusal, FC: 60 bpm, AQRS~0°,unda Q pozitionala in DIII, complex QRS cu durata de 80 msec, cu aspect discret fragmentat in DII, aVF, V1, subdenivelari de segm. ST in DIII, V1
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ECOCARDIOGRAFIE•VS nedilatat sever hipertrofiat concentric
• FE 55%
•AS dilatat
•Regurgitare mitrala cu jet excetric directionat catre septul interatrial
•Usoara hipokinezie de perete inferior bazal si infero-lateral apical
•Functie diastolica – relaxare intarziata
Parasternal, ax scurt
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RMN VS:- volume normale, functia sistolica normala -FE: 68%-Indice de masa crescut, valoare maxima in diastola – 1,4cm-Fara arii de reducere a grosimii miocardice-Fara modificari de cinetica globala sau regionala
VD:-volume normale, functie sistolica normala-FE: 61%-fara modificari de cinetica -fara leziuni anevrismale
Atrii in limite normale. Aorta, artera pulmonara, pericard in limite normale.
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Postadministrare de substanta de contrast:
-fara zone de tromboza intracardiaca -fara obstructie microvasculara
-nu se evidentiaza priza de contrast Fara zone de cicatrice sau fibroza!
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VS
VD
VS
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DISCUTII TV + PROLAPS MV
-cord structural afectat
-cord normal
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CMH I/II ARITMII VENTRICULARE -HVS PE CORD NORMAL -TV monomorfe – 70% - hipertrofia septala -asimptomatici / palpitatii, vertij, rar sincopa. -AHC: moarte subita
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Modalitati de management in tratament:
TERAPIE ABLATIVA vs ICD implant
Ablatie asistata 2D (CMH) (Majoritatea pacientilor cu tahicardie ventriculara, dar fara boala coronariana
Ablatie asistata 2D (CMH)
Ablatie cu abord epicardic
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Multumim !!!