Recomendaciones para la evaluacin de vlvulas protsicas con ecocardiografa y ecografa Doppler

Recomendaciones para la evaluacin de vlvulas protsicas con ecocardiografa y ecografa DopplerRicardo Poveda JaramilloFellow Anestesia CardiovascularUniversidad CES

thereis no ideal valve, and all prosthetic valves are prone to dysfunction.Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

Tipos de vlvulas protsicasLos tipos de vlvulas ahora implantados incluyen: Vlvulas mecnicas de dos velos/disco basculanteXenoinjertos porcinos y pericrdicos con stentXenoinjertos porcinos sin stentHomoinjertos cadavericos y autoinjertos (procedimiento de Ross).Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

Stentless valves were introduced to increase the effective orifice area (EOA).3

Tipos de vlvulasVlvulas biolgicasDuran 8-10 aosNo anticoagulacinNo clicVlvulas mecnicasDuran >20 aosAnticoagulacin de por vidaClic

Tipos de vlvulas protsicasLos diversos tipos de vlvulas pueden diferir tambin por su posicin de implantacin con respecto al anillo de la vlvula:Intra-anularParcialmente supra-anular Totalmente supra-anularZoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

La posicin supra-anular est diseada para maximizar el rea del orificio disponible para el flujo. El tamao mximo puede entonces estar limitado por el dimetro de la raz artica o la posicin de los ostium coronarios.11

Evaluacin de vlvulas protsicas con ecocardiografa y Doppler: Recomendaciones generales

Datos clnicosRegistrar altura, peso y superficie corporal.hay mismatch?Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

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En la evaluacin ecocardiogrfica:El movimiento de apertura y cierre de las partes mviles de la prtesis (velos para bioprtesis y oclusores para prtesis mecnicas)La presencia de calcificaciones en los velos o de densidades anormales adheridas al anillo de sutura, oclusores, velos, stents o jaulaEl aspecto del anillo de sutura, incluida la inspeccin cuidadosa de la separacin del anillo nativo y el movimiento anormal del balanceo durante el ciclo cardaco.Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

Mild thickening is often the first sign of primary failure of a biologic valve and is a signal to follow the patient more carefully.Rocking motion of a replacement valve is almost invariably a sign of a large dehiscence in the aortic positionLa raz artica puede estar engrosada como resultado de hematoma y edema despus de la insercin de una vlvula sin stent dentro de la raz artica. Esta apariencia, que inicialmente se puede confundir con un absceso de la raz artica, usualmente se resuelve entre 3 y 6 meses14

Qu mediciones Doppler hacer?Mediciones Doppler1. Velocidad & gradiente pico2. Gradiente medio3. VTI4. DVI (cociente entre la velocidad del tracto de salida del VI y la de la vlvula)5. EOA6. Contorno de la velocidad del jet; tiempo de aceleracin7. Tiempo de hemipresin8. Otras evaluaciones: determinacin de tamao y funcin de VI y VD, tamao de AI, y estimacin de la presin arterial sistlica pulmonar

Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

Heart rate reporting is essential. 15

Determinacin de los gradientesEn pacientes con prtesis articas y alto gasto cardaco o un tracto de salida del VI estrecho, la velocidad proximal a la prtesis puede ser elevada y por lo tanto no despreciable (velocidad proximal >1,5 m/s).Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

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Ecuacin de Bernouilli

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Ecuacin de Bernouilli para ecocardiografa

Recuperacin de la presin: condiciones hemodinmicas

The smaller central orifice in bileaflet valves may give rise to a high-velocity jet that corresponds to a localized pressure drop that is largely recovered once the central flow reunites with flows originating from the two lateral orifices. CW Doppler recording often includes this high-velocity jet, which leads to overestimation of gradients and thus underestimation of EOA19

rea efectiva del orificio

DVI

Contorno de la velocidad del jet; tiempo de aceleracin

Tiempo de hemipresin

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Tiempo de hemipresinTHemipresion = 0.3 x Desaceleracion

It is not appropriate to use the pressure half-time formula (220/pressure half-time) to estimate orifice area in prosthetic valves. This is valid only for moderate or severe stenoses with orifice areas 0,85 cm2/m2Mismatch moderado: EOA entre 0,65 y 0,85 cm2/m2Mismatch severo: 500)Variable (200-500)Agudo (3 m/s80%71%Considere hipertensin pulmonar residual postoperatoriaVolumen latido del VI >30% del sistmicoModerada sensibilidadEspecificoRM significativa se sospecha cuando la funcin del VI es normal o hiperdinmica y VTILVO es 3 m/s o >2 m/s a travs de un homoinjertoIncremento de la velocidad pico en estudios seriadosAlteracin de la funcin del VD o elevacin de la presin sistlica del VD

Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

These in general apply to most prosthetic valves and exclude homografts, stentless valves, and percutaneous prostheses, because the latter have flow dynamics that are close to native valves.69

Examples of a normal prosthetic pulmonary valve and that of an obstructed pulmonary homograft showing dilatation of the right ventricle and a deformed septum. The obstructed homograft had a maximal gradient of 64 mm Hg.70

InsuficienciaCriterios ecocardiogrficos y Doppler para la severidad de la RP protsica utilizando hallazgos de TTE y TEEParmetroLeve ModeradoSevero- Tamao VDNormalNormal o dilatadoDilatado- Estructura valvularUsualmente normalAnormal o dehiscencia de la vlvulaAnormal o dehiscencia de la vlvula- Tamao del jet por Doppler color (jets centrales)Delgado con un origen estrecho; anchura del jet 25% del anillo pulmonarIntermedio; anchura del jet 26-50% del anillo pulmonarUsualmente grande con un origen amplio; anchura del jet >50% del anillo pulmonar. Puede ser breve en duracin.- Densidad del jet: Doppler CWIncompleta o tenueDensoDenso- Velocidad de desaceleracin del jet: Doppler CWLenta desaceleracinDesaceleracin variableDesaceleracin aguda con terminacin temprana del flujo diastlico- Flujo sistlico pulmonar Vs flujo sistmico: Doppler PWLigeramente incrementadoIntermedioGrandemente incrementado- Reversin del flujo diastlico en la arteria pulmonarNoPresentePresente

Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

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Evaluacin de las vlvulas protsicas tricuspdeas

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EstenosisHallazgos sospechosos de estenosis de la vlvula tricuspdea protsicaVelocidad pico >1,7m/sGradiente medio 6 mmHgTiempo de hemipresin 230 msec

Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

These in general apply to most prosthetic valves and exclude homografts, stentless valves, and percutaneous prostheses, because the latter have flow dynamics that are close to native valves.73

Transthoracic echocardiographic and Doppler images in a patient with normal prosthetic tricuspid valve and another with prosthetic stenosis. The case with normal prosthetic valve function had mild TR and a large central inflow jet in diastole. The patient with tricuspid valve stenosis had an eccentric narrow jet with an elevated velocity and mean gradient.74

InsuficienciaCriterios ecocardiogrficos y Doppler para la severidad de la RT protsica utilizando hallazgos de TTE y TEEParmetroLeve ModeradoSevero- Atrio derecho, ventrculo derecho, VCINormalDilatadoMarcadamente dilatado- Estructura valvularUsualmente normalAnormal o dehiscencia de la vlvulaAnormal o dehiscencia de la vlvula- rea del jet por Doppler color, nicamente jets centrales (cm2)10- Ancho de la vena contracta (cms)No definido0,7- Densidad/contorno del jetIncompleto o tenue, parablicoDenso, de contorno variableDenso, con pico temprano- Flujo sistlico heptico por DopplerNormal o disminuidoDisminuidoReversin holosistlica

Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014; quiz 1082-4.

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Gracias

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