Valutazione ecocardiografica di una stenosi valvolare aortica

1. Stenosi valvolare aortica (SVA) : valutazione ecocardiografica (Dr. Antonio Federico)

2. Memorandum: 1) per la valutazione della severità della SVA non basta la stima del gradiente e della velocità transvalvolare 2) La severità della SVA è data dalla misura dell’area valvolare Metodi per la stima dell’area valvolare: Area anatomica Equazione di continuità

4. Continuity Equation LVOT flow = AV flow = A AV x TVI AV A LVOT x TVI LVOT A AV = (A LVOT x TVI LVOT ) / TVI AV CP1061805-18 TVI LVOT By PW A LVOT V AV A AV V LVOT Time TVI AV By CW Time

6. Doppler Echocardiography: Multiple Windows Apical 60% Right parasternal 19% Subcostal 8%

9. Valutazione area valvolare aortica con ECO 3D

12. Valutazione area LVOT con ECO 3D

15. Pressure Recovery Più il flusso si avvicina all’orifizio stenotico più aumentà la velocità (Energia cinetica) e si riduce la pressione (energia potenziale). A livello della stenosi sarà quindi massima la velocità e minima la pressione. Subito a valle della stenosi inizia il processo inverso: si riduce la velocità ed aumenta la pressione.

16. Copyright ©2000 American Heart Association Garcia, D. et al. Circulation 2000;101:765-771 Schematic representation of system composed of left ventricle, aortic valve, and ascending aorta, with corresponding static pressure (P) and energy in terms of total pressure (P+4V2) ,

18. Copyright ©2000 American Heart Association Garcia, D. et al. Circulation 2000;101:765-771 Variation of energy loss as a function of EOA (left) when AA remains constant and as a function of AA (right) when EOA remains constant. ( Transvalvular flow rate: 250 mL/s)

19. Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply. Bahlmann, E. et al. J Am Coll Cardiol Img 2010;3:555-562 Reclassification From Severe to Nonsevere AS by Pressure Recovery Adjustment ELI= AVA x AA/AA - AVA BSA

21. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Tribouilloy, C. et al. J Am Coll Cardiol 2009;53:1865-1873 Prognostic Impact of AVR in LF/LGAS Patients Without CR on DSE Absence of CR during DSE was classically defined as the absence of increase in stroke volume of 20% compared with the baseline value

22. Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply. Tribouilloy, C. et al. J Am Coll Cardiol 2009;53:1865-1873 Influence of MPG and CAD on Survival in LF/LGAS Patients Without CR on DSE

23. SVA PLF (Stenosi valvore aortica con paradoxical low flow)

25. Copyright ©2007 American Heart Association Hachicha, Z. et al. Circulation 2007;115:2856-2864 Overall survival in the patients with NF and in those with PLF

26. Copyright ©2007 American Heart Association Hachicha, Z. et al. Circulation 2007;115:2856-2864 Overall survival according to valvulo-arterial impedance (Zva) ZVA= SP + M.G. SVi

27. Copyright ©2007 American Heart Association Hachicha, Z. et al. Circulation 2007;115:2856-2864 Overall survival in the patients with NF and in those with PLF as a function of the type of treatment: medical versus surgical

28. Characterization of 512 consecutive patients with severe AS (AVAi <0.6 cm2/m2) and preserved ejection fraction (>0.50) based on for SVi > or ≤35 mL/m2 and mean pressure gradient > or ≤40 mmHg (data taken from Hachicha et al). Dumesnil J G et al. Eur Heart J 2010;31:281-289 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.

29. Overall survival in the four groups of patients (Figure 2) as a function of the type of treatment: medical vs. surgical Dumesnil J G et al. Eur Heart J 2010;31:281-289 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.

32. METODICHE DI VALUTAZIONE DELLA FUNZIONE SISTOLICA DEL V. Sx.

33. Teicholz e Simpson

34. 3 D

35. Funzione sistolica V.Sx. Strain longitudinale

36. Strain circonferenziale

38. Altre modalità di valutazione della funzione sistolica globale del V. Sx

40. Rischio bassa portata post CCH per ostruzione intraventricolare ( I.V.A.F.V.: intraventricular abnormal flow velocity)

42. MORBILITA’ PERIOPERATORIA POST SVA (casistica MCH 2005) BASSA PORTATA (Tot. 105 : 30 %) 5 3 16 81 (77 %) (15 %) (5 %) (3 %) N.B.: I Pazienti a maggior rischio sono quelli con F.E. > 50% !!!!

44. I.M. moderata associata a SVA severa: quando sostituire anche la mitrale ?

48. PAVR (Percutaneous aortic valve replacement)

51. Among 135 patients with normal exercise test 67 had an event (AVR for symptoms or cardiovascular death) at a mean follow-up of 20+14 months. The variables independently associated with events were: . age ≥65 years, . diabetes, . LV hypertrophy, . resting mean gradient > 35 mmHg . exercise-induced increase in mean gradient > 20 mmHg

52. Event-free survival as a function of the level of rest mean gradient (A), increase in gradient during exercise (B), and combination of rest gradient and exercise-induced increase in gradient (C). Maréchaux S et al. Eur Heart J 2010;31:1390-1397 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org

56. Non dimenticare che il gradiente è flusso dipendente e che perciò un gradiente basso non significa necessariamente stenosi non critica Oltre alla F.E. valuta perciò anche la gittata sistolica e il postcarico del V. Sx