La stenosi valvolare aortica nellanziano: diagnostica
ecocardiografica Maurizio Baroni Bologna
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The Euro Heart Survey on Valvular Heart disease Iung B, EHJ
(2003); 24:1231-1243 3-4 % popolazione sopra 75 anni
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The Euro Heart Survey on Valvular Heart disease Eziologia della
stenosi valvolare aortica Iung B, EHJ (2003); 24:1231-1243
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Otto C. NEJM 2008; 359:1395-98 Histopathological features of
human aortic valves removed at surgery or necropsy were the first
to support the hypothesis that aortic valve stenosis is the result
of an active inflammatory cellular process characterized by
lipoprotein deposition and molecular mediators of calcification.
Natural history of valve
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Storia naturale della stenosi valvolare aortica a seconda della
severit nell anziano Iivanainen, Am J Cardiol 1996 476 patients
75-86 y.o. 412 no AS (2.1 cm2) 25 mild AS (1.2 cm2) 26 moderate
(0.9 cm2) 13 severe AS (0.6 cm2) 4-year follow-up
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Survival of asymptomatic patients with severe aortic stenosis
versus age-matched US population Pellikka PA, Circulation 2005;
111: 329095
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Survival of patients with aortic stenosis over time
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Mean survival of patients with symptoms of AS Schwarz F,.
Circulation 1982; 66: 110510.
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VALVULOPLASTICA AO TECNICA VALVULOPLASTICA AORTICA
Guideline criteria for severe aortic stenosis ACC/AHAESC Aortic
valve area (AVA) 50 mmHg Maximum aortic jet velocity > 4
m/sec
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Equazione di Bernoulli (semplificata) Gradiente pressorio = 4
V2 GRADIENTE PRESSORIO Equazione di Bernoulli
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GRADIENTE TRANSVALVOLARE MEDIO Calcolato automaticamente dalle
macchine Buona correlazione con il gradiente medio calcolato al
cateterismo
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Ao Vel AREA VALVOLARE Equazione di continuit LVOT area x LVOT
Vel Area valvolare aortica = AVA = x r 2
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Non sempre si riesce a registrare bene la Velocit Massima
(allineamento non corretto, finestra inadeguata, ecc)
Posizionamento impreciso del volume campione del PW Doppler nel
LVOT Misura approssimativa del diametro del LVOT nelle forme
calcifiche e nelle marcate ipertrofie settali Assunto teorico:
Forma circolare del LVOT. Profilo di flusso piatto nel LVOT I
gradienti stimati al doppler sono flusso dipendenti: Incremento
stroke volume: sepsi,anemia.. Diminuito stroke volume: disfunzione
ventricolare sinistra Pitfalls
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Altri indici di severit Doppler velocity index Fractional
shortening - velocity ratio Ejection fraction velocity ratio
Resistenza valvolare aortica RVA Stroke work loss SWL Energy loss
index ELI
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Doppler velocity index Rapporto tra la velocit nel TEVS
misurata al doppler pulsato con la velocit transtenotica aortica
misurata al doppler continuo LVOT TVI/ AV TVI < 0,25 suggerisce
la presenza di stenosi aortica severa
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Ejection Fraction - Velocity Ratio E il semplice rapporto FE /
gradiente massimo Doppler EFVR = Frazione di Eiezione / 4 x Vmax 2
Frazione di Eiezione VmaxGmaxEFVR 303.5490.61 503.5491.02
703.5491.43
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Severe aortic stenosis: Indication for AVR Symptomatic patients
Patients with severe AS undergoing coronary artery bypass surgery,
surgery of the ascending aorta, or on another valve Asymptomatic
patients with severe AS and systolic LV dysfunction (LVEF,50%)
unless due to othercause Severe aortic stenosis: Indication for AVR
Symptomatic patients Patients with severe AS undergoing coronary
artery bypass surgery, surgery of the ascending aorta, or on
another valve Asymptomatic patients with severe AS and systolic LV
dysfunction (LVEF,50%) unless due to othercause
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Aortic stenosis Should asymptomatic patients with severe aortic
stenosis undergo to AVR ?
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Aortic stenosis Are asymptomatic patients with severe aortic
stenosis really asymptomatic ?
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Test da sforzo Elettrocardiogramma: angina, dispnea,
ipotensione, aritmie, sottolivellamento ST Ecocardiogramma: aumento
del gradiente medio
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Severe aortic stenosis:Indication for AVR Asymptomatic patients
with severe AS and abnormal exercise response Development of
symptoms Development of hypotension Ic Severe aortic
stenosis:Indication for AVR Asymptomatic patients with severe AS
and abnormal exercise response Development of symptoms Development
of hypotension Ic Severe aortic stenosis: Indication for AVR
Asymptomatic patients with severe AS and abnormal exercise response
Development of symptoms Development of hypotension IIB Severe
aortic stenosis: Indication for AVR Asymptomatic patients with
severe AS and abnormal exercise response Development of symptoms
Development of hypotension IIB
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Aortic stenosis Should asymptomatic patients with severe AS
undergo to AVR ? ..when they are really asymptomatic? Should
asymptomatic patients with severe AS undergo to AVR ? ..when they
are really asymptomatic?
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Severe aortic stenosis: Indication for AVR Asymptomatic
patients with severe AS and moderate-to- severe valve
calcification, and a rate of peak velocity progression 0.3 m/s per
year IIa Severe aortic stenosis: Indication for AVR Asymptomatic
patients with severe AS and moderate-to- severe valve
calcification, and a rate of peak velocity progression 0.3 m/s per
year IIa Severe aortic stenosis: Indication for AVR Asymptomatic
patients with severe AS high likelihood of rapid progression (age,
calcification e CAD) IIb Severe aortic stenosis: Indication for AVR
Asymptomatic patients with severe AS high likelihood of rapid
progression (age, calcification e CAD) IIb
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Stenosi aortica con ridotta funzione ventricolare sinistra
Gradiente sistolico transvalvolare elevato Gradiente sistolico
transvalvolare basso Disfunzione miocardica primitiva Disfunzione
miocardica da afterload mismath Corretta valutazione della severit
della stenosi ? Pseudostenosi Stenosi aortica vera
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Low dose dobutamine echocardiography Rationale Low dose
dobutamine results in increased contactility Severe fixed AS:
increased peak and mean velocity/gradient, non change in AVA
Relative AS: no significant change in peak and mean
velocity/gradient, significant increase in AVA or may be no
contractile reverve no response to dobutamine : nothing changes ?
?
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Transthoracic echocardiography is recommended for re-evaluation
of asymptomatic patients: - every year for severe AS; - every 1 to
2 years for moderate AS; - every 3 to 5 years for mild AS. Il
follow-up