Capitotu23

VALVULOPATIILE

D. Zdrenghea, Dqna Pol

ReprezinualbcliLrDilc curdiacepentu carcccocArdiogra" cu rcduccrea mobilitali valvularc$i a supraf€lei orificiuhri

6a a li,st rnip&lufllizataii penrrucarc(anlirar.:nii precrzrJ milral,cu calcifierea secundaril, tardivl, a cuspelormitralc
inlbmuliilor trrnizateestemaximtr.irr consecinla. atunci (rcmanicrea valwlarr) ll.
cind acesteatacliunisunl izolAtc(ftrralasociere cu cffdio- Di{igrostioulstenozeimilrslciD modul M esrecel nal
patiaischemictr, cardi(nniopAtii, etc)ti candcxist! irdicaliA facil diagDostic ccocardiografi c.
corcctici br chhurgicale, aceastasepoatccfcctUn cxclusiv in . Cel nai const{ntii mai importanlscmncstcnl.ir:!rr.,!/
bHzadrlcbr eco-l)oppler. explorarcahcmodinamica invazivll tlid$t)lh'n unkriottii a loitei Nsk:t iourc. re^tltatal llziutlii
(outclerism cardiac.angiocardiognrfi c) neffind necesartr.in comisurilor$j rractiooilriiin di&srollI foitei posterioarc dc
majoritatea cazurilor cate ceaanlcrioarl (fig.23.l).
Stcnozr mitral?1 Senolcazi.dc sscmenea. lcful$eu ponttliIi1.\f'9.23.2)
pini la aspeclul in plul()rlal foil€i mitrale&nlcnoarc, conse-
Estcprimavalvulopatie diagnosticallccocardiogmfi c. cinlna sciideriimobilittllijv.rlvulare iia ffbrozlrii !ilvci. irr
lltiologiasaeslecvasicxch$iv rcunratismalAii predonrini stcnozanritrali strensiundaA displrc (fi9.21.3).disp0ritia
n€tla sexulibninin. iarprcvalcnja saestein declincaunnarc aceslcia llirdprczenu.iMiferenldc gr.dul stenozei rnitmle,
a scAderii cnclcmicircumrtismale. In consecinF. dcti tcorctic in cazde librilaticatriah.
seindlnc$tcla varsUtanArr.cazurileactualcpredominA la Scid€reanobilitalii foilei anterioare (dislaDFDl) re-
virstelem€diisauchiruinainlnD$inu suntde rcgulasevBre prczint!un semnasociaL carc.din picaie.nu corclcazlcu
(doarformeleu$oareii mcdiipcrmilandsupravietuirea pe o sevcnhlcas1€nozei miirale.
perioada lungndc timp).Un pfocentsemificati! al stcnozci Esrcinrportanti.r".T/dr?d..!seniLttdlii lb itck . reltu late
mitralccslcrcprczeniat de stenozanjlrala opcratr.prin val- carein cazurilcselere(calcifiere vahn rcmaniat.tdevine
vuhronrie(conrisuroronie) sauslcrozamitraladilatard(cu mult slrp€rioarl cclcia miocarduhi(1iC.2.1.4).
balonai),SM op€rahcu protczarcvalvularifiind descrisa Actualmente severilaba stcnozei rnitrale(pmtaE-F)ntrsc
intr-uncapibl scpamt. marcvalueaziinmodul M. daLorili impreciziei daElornrni"rr.
S(enoza nlitralA,caii celelalr€
vah,rlopadircumatismale. In nDdul U se evidentiazn aspcctin ciocan(in arc) al
rcprczinlidefaptcicatric*er ocarditcircumatismal€ care, valveinritftlc anterioare. tracliunea in diaslolia foilei pos-
in carul SM, rezultdh sudncafibrotid a foitelormitale re'iodre d(.,,r'r i 'ild0nrenoari >r. a.crnrn\.z,
de n mrnierca
 t , , '! a l d , ', J r l u t t t 't '. 1 d . 1 a h a . d t nn i

ai& ?.t /. ScctiL[cparastc,

na]t a\ lufs. !.o NI.NtiicrLedianolici ai&2-1.-tSN1scctiunctarns(emdl.ax lung Irco-M DNlmnlrr
anlcrn)arir n)ilcipos{erbare. undciApnn lbtuzi !.lruldi.

lt&?L,L S\.1sceliu|eprLlsrcmld.x lutrg lieo-\.l VrlviDilrrlal

re'rnii.i! cu ccogcnicilarc (culcillci)
nrullcrcscura
Iik2J.2. SV. Scc{it'ncfalastchalii!r luns. E!o-M scrdcrcr
p a rl cili|.

\a1\'rrlararpfin crcgcrca iml)ortantna nnensila(ii ecourilor RS,darl,rdcosebiin SM ouFiA)rinonnalilatea dirncnsiunilol

re d e ct at de e f oilelcv a l v u l a rc(1 1 9 .2 1 .5 ). VS (ir SM pu|i. fcasociaii cu IM sdutAo)[3].
Cel lnai iLnpolrnt {cmn cstc rcprczcrltdtdc diilirtuarcr in mornertul apariticiIllPscDorcaraLraspect carrc-
supLaleleiorificnrlui lahular. cvalLrNlliD prrdslcmrl rxn lcislic !l \'alveipulmor re (disFrilir undci '4"). urtujrea
scu fl I ( 6g 23. 6) .int r e 1 .5 -l c rn )SM c s rcc o D s i d c ra h l rrgn. dinrcnsiurilor VD iiaplrltianriicirii prfutuxalc a SIV
i n l rc l - 1. 5 c r nrm edie .i a r s u b I c n rrs tri n s nSc
. u ti l i z cu! ti EcograliaDoppleresteutil, atil pcntrudixgnosricLrl de
cldluarea orilici lni rnitrrl pe rn) supraldlacor]!tuh. sM :V. JJr nd(u.el.rp< rrrlr<r.'rrr.r""r .'ri."...r.rr i nr|'
'
liind cons erlrlastrilrsi slrb I cnrrln' sinusrl.nrDPsauDt. senoreaziLrn.rsfccldc V in\crsxlGa-
Sc poalc c\idcrlia 91rernanierea.rparatului sub\allulrr pofl l,'A subunriar)(lig.2i 8), rafin SM sc\cri'rspccL ph-
.o rdoic .pilic r i ( 1ig.l 37 ) i 2 l rrilrale(i deosebi
rr)ual \clocirntii in SN1nr liA) (1ig.21.9).
( r scnrncrsrcialc. crre pot fi evaluaieatit in modul M rfrrrJ pu:t<h rr itrl:,t: rtr rtr.t
5,rf,:,1.,r.,'r'lr.r.lur
.rir ii iD.rtrlulB. Dolnri nl.r]rea fifiulLri stiing(rtril in SM ln acuralclc.riliDDP cil fi in DC,din poTilic,rficrl.i.dncclir

LI-
 101

r,&2.1Z SM. lco-R. Sccllunctdrasrcmallax scurl.Rem.niere!

apamrului{rbv.l!ul!r (sigeata).

prastemaldax lung.Aspectinarc
Fr&23.t SM. Eco-B.Ssctiune
alvMA yi cre$treaecogenicitnli.

Fia.23.8,SM ln RS.S€ciune4 camere

apicai.DP.AspectdeM invc$ot.

cu ceadin ecogralie:SM larg! 1,5-2cm':,SM nedie l- 1,5

cm:;SM stens,< I cm':,daracuratetea dateloroblinuteprin
prin
DopplerestesuperioadceleiobliDute ecografia B [2].
in diagnosticulstenozeimisale est€impotantasi determi-
,Fk 2J.6.SM.nco-B.Sccliun€ para$l,eall axscurl.VM c! OM
nareagradientuluidiastoliciransvalwlar,un gxadi€nrm€diu>
2 mmHgofbrindccrtitudineadiagnosiiculuidestenozimitul4
iar ungrrdicnt> I 2 mmllg indicandlbrmalinlervenliachirur-
fascicululuiultasonic fiind aliniatecu fluxul de curgcrc gicaltr,deoarecc exisli risculaparifieiedemxluipulmonaracut.
Dopplcr-ulcolor nu arc unrol deosebilin evaluareasteno-
Sc utilizeazamai multe metode,dintre careaceeaa PHT zci mitralc.darpcrmitedepislaiea rapidl d facil, aacesteia
r..pre(surchrlf rime'resrecea maifolosira. Evaluarea severi- prin tentade mozaic r fluxuluidiasiolicdinAS in VS, prin
trlii SM in funclie d€ suprafalaorinciului mitral esteidentice
302 Eogruliu cor.lului si wseh, .le Id bdzd iniklii

li&L9. SMscvcri IiA Scctiunc ,rcanereapi..l. DC.Aspeclin

I'j&2J./A SM.lrtsB. Abordlr.Nesoi4iar. Scoliuicttuns!caalr.
plato! !l \clocitilil ( liril und.A).
'nirrxle

i rr Lr oLlul2- { . 1.t r u n rs u rn a ri l a re!ri r(L l L L l r :c \J fl rdrJ

din slcnoz& itral:l.
Sc dcpistcazi. de asel[enea.tromboza atfiala stenga.
AccrislnpoatcIi suspectattr ir lnodul M.vizualizatnin modrl

in srcno/ainitBlil
?irtul211. Cdtcriidc scvcrit0rc
SM sv sM

r,5 -2 1 .5 -| .r I
f5 6-12 )12

0 0- 1 5 0 t5 0- 2 0 0 l :2 0

ll transromcic. dar estediagnosticatl cu acuralclcmaximn rk23.ll Cronrd$hASprinsleno^scvedi

SM.Elo rrnr$esolhgim
priDccogralia lrnnsesot'0gimtr[1] (1i9.23.10)la lcl c.r fi
contl'asrulspontaD (1i9.23.
I 1).
lcogrlli.r Dopplcrpenniie,de asemenea, dcpislarca tI- Insuticicnta
mitralA
milralcsru insuficieufei
cill a insullcicDlci aodiceasociate. Insuficicn(nmitnh (3M) esle la ora actualtrcca n]ai
prccurrii .tnarili.rcomplicoliilor.
respectl!a hipenensiuni frccvcntinlalnilAvalvulopatie. EtioloSiarcumatismalll cslc
puInon.rrc.insuliciclr!ci
pLrlmonarc ri msulicienlei
tricuspi- ml5, nraialcs in asocicrccu SM. Donrinnetiologi.tncrc'
diene,caii oalcul.rrcagraduluilripcrensixnrlpulnonffe(in pfol.rpsdc !.rhn mirala.cardiopatie
uInatisnrali: ischcmicat
(distuncliedc pilicri. rupLL,rI
dc cordaje),calcifierea dc incl
tr bazaexaminiriil)opplcrscpoaLc elccluaii indicaliade nitnl. Cauzele funclioDalc (dilalarea ineluluilnilral)suntii
nrtenendechirurgical,(in afarasnnpldnrLologici cltuicc), e1etiecventinteInite,irdcoscbinrcardiomiopatia dilataii\'4.
LndicalieadusddeOM.:I cm'lduri uniiLrurui).dcprczcn(r darii in altecazufideinsuficicnlar crrdiacasstolicnsaudila-
IITI de irombozaatrialastAngi.llstc uriln ii iD clxluLrrcr larea VSin gercml(insuficienla aofticlclc).Rar,darcu con-
rczultatelorintervenliei (valvuloLonric)
chirurgicalc f rccum sccinlednmatice (lVS acuti. l-.PA.dcccs).csleinsxlicienia
ii in depistarea
$i e\.'aluarea (SM
reslenozarrii itcrativ!). milrah din endocardiia bactefianat (prinpcrlbrarevalvulari)
 303
saulM apiruti in cadrulevoluljei iMA, prin rupturdpa4iald
sautotah de pilieri [5].
in ecografiaM qi B nu existi semnespecifice aleinsufi-
cienteimitrale,semneleecograficederivanddin incircarcade
\ oluma venrncululur steng)i arriuluisrdng.Deaceea. in'u-
ficien(e1emitraledesradmic, cu semnificatiehemodinanica
redusl, pot tumiza o imagineecograficanormal5
in In"uficienta
mitralaserntri6cativa hemodinJmic seno-
teaznmldr€a devolum a atriului staflg,expansiunea sistolici
a pereteluiposterioral atdului stang(inconstant,in ecografia
M), creitereadnrcnsiunilordiastolicealevmtriculului stang,

parislen'.lli
fi&2i lJ. tco.ts.Secliune a scun.
Calcilierea
inehlui
hrtralpostcrior(sigcata).

IM sausccastacstcncscmnili€ativ[hcmodinamic, avand
consecinlccliniccminimcsauabscntc[6].
Prolapsuldc v6lvi miirah cstcunadintrcafcctiunilcin
carcccogralia ofcrdcclcmaiimportantc dltc diagnosticc,in-
difbrcnidaclaccsta csrcsaunuasociat cuinsu{icicnla
mitrald.
Fl&2112Secliunc parartcrnouaxlung.Bco-M.lM scmnincativa. ln ccografiaM scmnulprincipal csic rcprczcntatdc
VSdilaiat.hiperconLraclil. dcplasereaposterioartr,ln sistoll,a unciasauambclorfoilc
alernitralei.In prolapsulmezotelesistolicaceasttr
deplasare
oferaun aspect in,,cuibde randunic!"(69.23.l4),iar ln pro-
cu hipercontractilitare(hiperchin€zie
de sept9i de perete
lapsulholosistolic un aspectin ,,hamac"(69.23.15). P€ntru
posterior)(fi9.23.l2).
in schimb.ecogmfiaM si B fumizeazadateimportante
in stabilireaetiologieiinsuffcienleimitrale.
DacAlninsuficienla mitralareumatismala nuexistisemne
ctiologicespecifice(in afaraasocieriicu stenozamitraln),
&ccstcscl'nnesunl prezenteln cazullM de alte etiologiil
c8lcilicrcaineluluimittal,prolapsdevalvi mitrala,etc,
ln Lrl(iticrcaineluluimital. in ecografia\4. se inregi-
streaziun ccouputemic,mai alesposteriotcalcifierea fiind
vizu&lizatidireclineco$afiaB, at6tin sectiune parasternaltr
ax Iung.cit ii ax scurt[5] (fig.23.13).
ir rupturarlecordajetendinoas€ nu exisg semnespecific€,
d{r.c L\ idcnliiraproldpsulfoilerrespective, portenoaresau
anterioarc, ir airiulstang.iar in ecogmfia B sepotevidenlia
uneoriecourialc cord&jclor(librozalesaucalcifrcate)in atriul
sting,in sistold.
PVM idiopaliccstc consideralca una dintrecele mai
frecventecardiopatiicongenilale,ffind Dotatintr-un Focent
ridicat,panala 2-4%.indcoscbi la scxulfeminin.Din lericire ai&23.1.t Seciunepdastemli a lu!8. Eco-M.PVM mezotclc'
mJjorirarerca,/urilordc PVV droparcnu 'e asociaTa cu sistolicin cuibderanduliod.
304 EcoBrafia .:oftlului ;i vdsalar de Io boza ininii

luhs.Eco-M.
liig.?t/-t Seqiuncpamstcnralaar livM holosistolic,
I'Vl asociat
fig.23.l7.E o-B Secliuncapicoln4cdmere. l\44.

certitudineadiagnoslicuhri dc PVM dcplasar€r posterioarl UneoriPVM sepoatcasociacu prolapsal V'I, delistrt

a ibitelorrebuiesl fic > I mm. exclusivln eco-U(1i9.21.17).
Sensibiljtatea
depistArii PVM orc\itcin ccografia B. piin Prolapsulidiopaticdc valv; mitraltrsecaracterizeazA ir
evideniereadeplasiriifoitclff sub plenul ineluluinitral. ecografia M gi.lndeoscbi, iDccograliaB. prindegenerescenlA
0ccasltrdeplasare putandfi evidcnlirti udt in poraslcmal nixomatoastra valvei, subformr unci ingro9trilsennificative
axi lungacat,nraiales.in api0Al4 cdnrcrc(lig.23.lO. Eslc a foilelormitfale.indeoscbia cxrcnridtriiliberea acestora
posibiladeplasarea posteriorda uncir sur nnrbcbrlbi{ccu (valvdin "maciuca")(ff9.23.I8).
pislrarcacoapttuii
acestom in si$t(tn(lAnivclulssusubplanul InsuficienlrnrirrulAprinrwturnhtltladepilienajungemr
incluluimitral)saucuabs€nla coaptarii rccslorain sistoli.caz sil lie diagnosticard rcprczcoland
ecocardiografio. o urgenld
in careinsuficienlamitralAasocirtlcstco rcgulil.Eatrcbuic majordcareevolueaza rapidcu cdcm pulmonar acut$i dec€s,
irsd confirmatiprinunadintremodalitllilccco-Dopplcr. ln schimb,in ruptura pa4ialtra unuimu$chi papilar,
in eco-

Eco B. Sccliunc4 came.edpical.Pv M al ambelorfoi(e,

4A.2J..16. pansremala
,Fi+?ild. Eco-U.Sec{iune d lung.IVM id'opatic
predoninentiol{aposorioariGrgeara). mixotn toasaaVM (valv.inr'\nnciuct ).
Degenerescenl!
 305
graliaM ii B sc evidenliazisennedc prolapsimpoflantal
uneiadinrc foilclemitrale,cu,,flulurarca" acesreia in diasrola
fi depla$rcannprtanti in atriulslAnga foifeiin sistoli.Dc
asemenc!. in ecografia B sepoalccvidentiarupturapa4ialir
a muichnrluipapi lar.
f,cografiaDoppl€r.Diagnosticulinsulicicnlcimitrale
prin DC, l)P ii indeosebiDCo. estede naxinrl acurateie,
putindfi depistate chiarii in$rfioienlele nitralc dcgradmic.
..liziologice".
salrinsrficic'nlc1cnritralenedepistatc rusculta-
roric.T)inacestpunctdc vcdcrcacumtetea eco-Dopplerpare
a fi superioard chiarsi angbcardiogmfiei l7l.
Depistareainsuficicnlcinitrales€poateclccru .(it in DC,
DPsauDCo,secliunca ottimAdedepistarc fiindreprezentata
de secliunea apicals4 carnere. ln DP $i DC re evidentiazi,
in sectiunea mai susamintiti.o velocirarc sisiolicAregativa
(frg.23.19),iarin Dotpler colorsecvidcnliaza o inaghe dc Fi&r2l. IM. Sectiune subcostala4canrere.Dc() Scc!idcnliazn
tip mozaic.sislolicn,in atriulsrang(Iig.23.20). inragine
detipfrozlicsubvalva
mitnlain sisrola(v.zi
colortlanta2).

fi&?J./q Sechn€4 cumcreapicrll.DC. Vebcirarcsistolict at&rJ,2r.lM.Scotiuncpffasl€mallstangA!x lung.DCo.lmaginc

negati!I,diagnosiicd
lcntruIM. mozaic subvalvdmihllil.IMgr.I/l I (!ezioolorplanF2).
sistolic{

Gmdulinsuiicicnlci mitralenupoatefi atrrcciat in DC,dar Doppler-ulcoloroferl in plusti ailc posibilitlli de eva-

poateIi acuratst'bilit in DP.9i indeoscbiir Dopplercoloi, luarea severifiliiinsufici€nlei
milralc.
dup,,.adancinca" in atriulstAngpeni la carcscinregiste^z a, Ctnd suprafalajetuluiregurgilanl(mozaicul) esre<4cn,.
insistoli. flux rcgurgitant (fig.23.21).in cazulincareacesta IM esteconsidcrati degradmic.intrc4-8cm:degradnrcdru.
se inregisrrcazl imediatsublbitelemitrale.pannh nivelul iar>8cm:caIM degradmare(1ig.23.22). Demenlional cI in-
ineluluimitrul, IM esteevalxatlca 6ind d€ gradulIi cend tle suplai4aietlrlui
regurgitantnrrcgistrati
in DClo}i mlnmea
lluxulrcgurgitant estenotatpenl la l/2 aAS,seevaluezza ca realeaielului regurgitantnu cxistl o corelalieabsolula. dar
gradII. iar canddepa$e$te aceaslldistanlicaSigradlll; cend aceasta din urmapoateIi relaLivacuratevaluanpnn supra-
1luxu1rcgurgitant atinge,,acoperirul" ('loof ') AS, respcctiv tblajetuluiregurgitant.
pcrctolcposterioralAS in 4 camcrcapical,lMestecodilicari Sc utilize^za$i raporlarc!suprafeleijetului rcgurgirant
dc gmdIV [8.9]. (mozaictrlui) la suprafala
atriuluis6ng.lM fiind considcrati
l0(i Ecosrord.ot lului Ii rt1t"lt, de ld bd.e inituii

rndicdcorecliachinngicah(!al!uloplssiie,proteTafe val
!uLari).ln schirnb un VS multdilxtal(DTDVSr'80 mm)
cu perlbnnarticontractilai scizutar (FE < 50'1")contraLndrc.i
rclali! intervenliachjnngicalnprin crc$terca irnpodantir
riscului perioperator llll.
Stenoza tricuspidiani
Esterari.dereguliasociat,cu scnozamjtrali.l-ltkrlogi!
sr cstcpnclic erclusivreLunatismali. Diagnosdcnl poatefi
cu ugluinli omisin caTulin c.lrccxmrinatorulnu estescn
sibilizd in acestserN.lneco-Maspech'lcstc asemAnitof clr
cel al slenoTei mitralc.scmnulprincipaliind fetrczcntltdc
Inr),rrJdd.dnolrc; anreriorri J l.,il.rI'',.lJnudre In.cnrnrb.
reinrnierea valvularn cslcrara. avindin veder€ rcgmul prc-
sionalredusdh ininradrcrpla.
i cco-BdixgnosticuL estedificjl deoarcccnu sc poare
pdrslcmala
li&2J.22 lM Seclrnne axlufe. D(lo.s||ptuh|.nt!
li cnrr.
zaiculuisistolic; (vezicolor
lM seveLi plesi2). electuaplanimetria orificiuluilricuspidian fi nu existno
limitarciliicl carc si tran$eze intresuprafal{lricuspidiani
nonnaldi' stenot'ca.
dc gradI candacestrapofiesle< 20%.dc grAdII intrc 20- in cco-Doppler diagnosricul poatcJiclcctrntalil in DPcil
40%9i de sradlll >40%[9]. Siin I)C, aspcctulvcbcililii rricuspidiene find h plntouin
Existt ti alte mijioacede evaluarc.r scvcrilsliiiosuii- cazdc stenozltricuspidiann (fig.23.23). Scpoatedetermrna
cicnleinitale, cumar li determ inArca jctului la origmcs{ru g.adientu I transtricuspldian diastolic mediuti, dc ascmcnca.
cvidcDlicrea ,,veneicontracta" dar,pdn complcxitalc. accstc& supraihla orif ciuluilrhc pidian.prinulilizarerrnetodeiI'HT
dcpnfcsccadrullucririj de fall [] 2,l.Rcdlmnr labclul23.2. (vcziSM)(lig.23.21).
crilcriilc de evallrar€aie se\,eritnliiIM in con{bnnilalcou Dopplcr-ul colorarco utiiitaiercdusn in disgDoslicul stcno-
rcconxrndiril€ SocietdtiiA nlericancdc tlcocArdiogrulic. zcitricuspidicDc dcoarcce. datont,velocitnlikn rcclusc alcini-
llvaluarca lM permitcstabilirca
severit?ltji alitudinii m.I dr(nl(..sp..ruI JLInozarc r I flu\,rlLrJrJ\lnh(tftnsLn(ujIr-
tcrApcuticc. in sensulct lM selcrl (gmdl-4, supralnF> 8 diADcstcdcrcgullabscnl. mozaiculfiind not0td(xirin mrjlocul
cnr:)saucu conscciule hemodinamicc inrportrnlc(AS mult jctLrluilrltnstricuspidian [3]. Cfiteriidc scvcrilutc alcslcnc'zc'
mlrit. VS > 70 nnn) cu contractilitatc nonnAll(fE >50r/d) triouspidicnc sunt:PIIT > 190rnsti grAdicnt mcdiu> 7 nnn.

rrit'nle(du l l2)
Iardl 2J,2,Porlmciriicdliritivi ir uantir!riviurilizatipeonlrcvrhrrc, !cv!riiltij in$Lncicnlci
II\I I\IODERATi
lARAVlTRI S r Rr.lCtLrRALr
N liccloni d atur
li.cv.Nd1ld.r
IALVFI,F $I AIAR^TI]L \i\L\iI]L,\R lnornrilc
Ml!c!r. du^rdorati a VM
d€rnu\clr pnl)rl.rr
!ltrpLrtri
P,\Rr\NlLlRll DOPPI.l.ll{
. r t r c d t r a l . l d g l - 'l o c n r r r l u , t 0 ! i 'd n , i 'i .
As) sr! j.r c\ceDrri.slIeFreel.Vs
p . . d o m i 'ruan d rl , 1 h , , 1 . n 2rs)

NiI p...occ.rflunghrl.r
PA]iAM}'TRII(]A\TITATIVI
. vohrnrulresurg,linlnil'bit.i.)
.lr.crrer deresulgnx'c(!i)
. xri. ofnc u, resursirnrrlccn!(.m') . . 20

[tE
 307
miopahceaVD (cardiomiopatie dilatativ!dc VD. displuie
de VD) clc.O menliuneapartepentruboxlaEbstein,in care
In'u6flenFIdcuspidiana (\re'c/Jlrlr.rl a|fah,,Jrii \ enrncu-
lului dreptpdn insefliajoasna valveitricuspide. Dodm sa
menlionimfi IirptulcA,in cazulunor leziunjlxlvularc al€
innnii sdngi,clinic,insuflcienta lricuspidiand estecontun-
dall frecventcu insuficienla nrituh, rezultanddiagnostice
de stenoze$i insulicicnllmitrali, saustenozeaodici $i in-
suficienhmilralr cend,in realitate, bolnavuls€aflaintr-un
stadiuavansatde evoluliein car€,prir HTB se realizeazi
insuficienldtricuspidiantlimcfionah fl 41.
EcograllaM $i B aducdatepulineii imprecisein diag-
nosticulirsuJicicntei tricuspidiene. Ea poatc{i blnuitl din
prczcntahipe(ensiuniiartedaicpulmonare.respectivdin
absenla undei"a'a valvcipulnbnue in ecografia M. ii din
fi&2J.?J. Scctiutrc,l cmere atical DC.S l' d{'cldrncu rT. spccr dilatarea !cnlricuhrn drcapti, respectiv cre$terca dinrc'nsiun i-
nr p1a1ou al fluxuLuilriclspidian. 1or!en(riculului drcpt!i miWareaparadoxala dcscpt,carcpot
li c\'idcnliale atAth ecogralla M cil riin ccografia B ll5l.
ll.chirnb.c(upr.uid D,'nnlr'r(frc/inrir<r Inrip(Ji,ir,l
maiutila tclrnicidc dcpistare a insullcienlci lricuspidicnc.
Studiulvcbc itlfii curbelorvenoasc in vcnacrvAsuperioa-
ra. vcnr cavi inferioafiti lcnaiugularl pot i utile,dar ele
suntfel depitilc cfl utililurcdirgnosticnde srudiulfluxului
transtdcuspidiun, sludiucarcportcfi efectuat in oric0rcdintrc
modalilalilc Dopplcr
Dir|gnostjcu I pozitj!al irlsullcicnlcitlicuspidicne esteacu,
Mi cfectuat alalin DR DCciilliiirrIX\) IX tiDPolcriinplus
posibilitritcii
studiului grl|(licnt hril|rrlslricUspiditin sistolicii
posibililalcrcvrluliriiprcsiuIiipulnrur fc sist('licc.i^| I)P)i
IXI) pcnnrievrlLrarc0 scvcrililiiinsullcicntei ificLrspidicoc.
llxIlniinrrcooptrm?l sc lirccdin 4 cI|rrrere.rpicrl. r^rD('
$i DP cvidcnliindu-sc o vcbcitlre sisiolici|cgalivi a carcl
afiplitudincesiedirectproporlioDaltr cu scvcritstcainsufi-
D a. S l ( 0 ru .trc J tri n md l l h PIIT
1t ie. 23. 21 cicnlcilricuspidiene. velocitatca ncgrti!I fiind in "degerde
' tl
manusl in DC (Iig.23.25)
Alunciclindvcbcitateasistolicd negativltraNlricuspidi.r-
Stcnozairicuspidiannnecesitiialirczolvdlichirurgic.rl in
nAcstcde intensitate m€diepol11utilizatcatatl)C cit $i DP
paraleicusienoza nirah, dereguhprinvalvuk)tomic, avind (vcntncul
dreptniopadc),darin cazuI velocittfilor cr€scure
in vcdereca la nivelulinimiidrepierenranicrca valvularleste
sepreteraLrtilizarca DC.dcoarece in cazulutiliznriiDPaparc
l.trlrtAlnit6.Dealtfelprot€zarea tricuspicliand
cstedificil tole-
l'enon]cnul dc repliere.
ra1,hemodinamic avAnd in vederc rcgnnul prcsionalredusdin
h, (d,,LrlUril,/irirD( o. dngln'ric,rl]1,'/iri\ ere rii!urrr
ininu drenpti.lncDzconlrar(ncrczolvarca saconcomitenie
de aparilia unei nnagnri mozaic sistolicesub valva iricuspr-
cu SM) esteposibilca persislcnl.r srcnozeitricuspidiene sa
diand.in trriul drcpr(fis.23.26).
compromitn rczulkrclcoblinu1c prin rezolvareachirxrgicah
Estnnarea severitiliilT esreelecluatloflinr in DPii D(lo,
nr DC aceasta liind doaroricnlalivh.in scnsulci velocita!
Insuficicnta tricuspidiani sistolicenegrdvcnr itrr dc 2 m,secsugereaza o lT de grad
Insunoientatricuspidianaeste.practic,in cvrsit('ralitatca u$or-mediu. irr vcboitarliinspre6 m,secsuger*zdo IT lna
cazurilor.de nabratunclionalaEsleintAhridaril iDcaTurile jor6.Dc asemenea. o velocitatelricuspidirnldirstolici >l
dc hipetensiunepulmonaricilt $i in cazurilcdc inlcrcsare m/sconfinnao 1Tsemnificativ![] 61.
30n Ecogruhd .a hl|i ti rdselot de la hd.o init,tit

poalcluain considcrarc raportuldnrbcsuprafalrjctului regul

gitanl(nozaic)f i suprafalaAI), unrxportjet rcgurgltalrl/Al)
> 40% sugerand o IT inpofianta.dc rcgula>6 cn: [17,l]l
in tabelul23.3.suntredat.crlleriilede cvsluareale ll
in conformitrtccu recomrnditdleSocieraliiAmencancdc
Ecocardi(,grafie.
Mcnljonin $i f.tptulci in DC cslc posibili .lrluarca
PAPS.rceastafiind cgali cu gradicn(ultrasvahularsistolic
maxim+ 10mm.cvalLrare deosebit dcimpofiantidcoarece in
majoritateacazurilor insufici€nF ldcuspidianarcslesecundarai
hipertensiuil pulmonare.
Sancliunea terapeuticn ricuspidiene
a insulicienici consli
in anuloplcstietricuspidiand caretrebuicclectuaticoncomF
lc t cu rezolvarea vrlvulopatiilorininrii stengipcntruci in
(d.,Lonrra_relu,Lr.l pnrr('{L.ridrLesl..
chirurgir,'1,'h!.nJl

ri&23..?5Sccliunc D(1.Il relevali!rnvclo(rntcr

4 c.mereapicll.
negalivi
in deinlnuia . Stenozaaortictr
sistolicn "dcgct
Nc vornrel-eriin trinrul rAndlr stcnozaaotlicn !rlvulari.
ceamai liecventdbcalizarea afecliunii.
in DP SiDCo sepo.rtccvaluagradulinsulicienteitricus- PoatcIi de etdogic congenitall.rcrmratisnrah saude-
pidicnc.similarcu gradulinsufici€ni€imilrale.depistarea gencralivi.La ora acluahceamai frccventdetiologiccsle
velocitalilorsisrolicein AD imediatsubvalvelricuspidianl ceadcgcnerativtrr SAo notau dupl vArslade 50-55dc ani.
preciTinddiagllosticul dc IT gtadl, depislarca acestorvelo_ indeoscbila sexulmasculiD, in cafeprimordialae$tccAlci-
citnliprinlla nivelul.t l/2 dirAD caracrcrizlrrd insuficienta stenoztvalvularlliind sccundafa.
ffercrvalvulara, I)c $ccca.
tricuspidlri degradII. irr drncoio de'rccslnivcl.lTdegrad a$ ounrsc va arita nMijos. severitat$sbnozei aorlicc nu
UI (fig.23.27).Atingefea plalin lui(,.roof)ADn punedi!g- polrtc1idcdus,laindiviziiviirslt1icidirr cAl0iticrii
inlcnsitateA
Dosticuldc IT gradlV I)c dscmcnea. seia in considerare.in lalvulurc 8l.
D(o. s pntlhFjetului rcgursitaDt (mozAic ul).sub5 cnrliind Pintrla varstadc trci aDistenozavalvulardaortici c$tc
vorbadc o ITde gradI. nrlrc5-10cmrdeo lT dc gradll. iaf> prlrcrici otdeaunr dcorigrnccongen virsli
it8l6.dc IaacelNttr
l0 cnrrdc o ITde grddlll (mtsivi). DeascmcDcli, in DCo.se 6ind ncccsaridiferenlicrci re etiologi!congenihlIii rc-

?J.?dSeclunc4 canrceapicalDCo.lT relevatipri! vcbcnAlile

.Flq. fA.?J.22 D(o. lT impotant!.gmdII (v.zj colorpla\. J l
sisrolicc lnozrlc" b v.lva tricuspidi (vczi color planla l).
 109
Iar./ z-t-t Pdamelriieco..rdiogmnci
ri Dopplcrutilizalipentrue\alulrcascverniliiin$,licientclirrcuslrdicne
(d!ti l2).
SEvERi
vl i.onnrlt nritrir rlezordomralc
\alvel{[ coorplarcilconplc$
vD'ADrv(l dim eNiuni
:5
rirymca lcncr ule (cm)
Dcn$lxleari.onruruljetuhi (Dc) dens.rrrunghiular!i
peakprccoc.
donlnunFconponc cishdicc

umatismala. ultimafiindlntahitdindeosebi h cazulasocierii La indivizii peste50 ani (SAo dcgcnerativi)calcifierea

valvulopatiilor (SAo-lAo.SAo-SM.SAoJM) ll 81. valvcipoatefi prezentdSi in abscntauneistenozeaonice
f,co-M ti B. Cele doui semnedircctc principrle ale scmnificative, fiind necesartr. pc dc o pafieevaluarea des-
stcnozciaodicein eco-Msuntreprezcnlalc de diminuarea chidcriivalmlaresistolicc,iar pc dc nlti partedeterminarca
deschideriisistolicea valvei aorticc< 15 nrm si de cres- Dopplcra gradientului transvalvular I9l.
tcrcaecogenicittrlii valvelor,respcctivcalcifiereacuspeloi Inregistrarea concomi|enti a diminuariideschideriivalvu-
(fig.23.28).Diminuarcadeschideriisistoliceesteun semn lsr!'-$icalcifieriicuspelorcrcstcacuratelea diagnosticului.
acuratde stenoza aorlicd,cu condiiiastrnu existealtecauze In stenoza aortic!congcDitaltr ii reumatismalA, darai in
dc debitcardiacscdzut.Din picatco dcschidere normaua stcnozaaoficl degenerati,rl (la bolnrvii f!r! hipertensiunc
valveinuexcludestenoza aortictr.
indcosebilnstenoza aor- arterialaasociatA). sunt importantegi semneleindircctc.
tica congenible(valv! bicuspidtr saumonocuspid.A) 9i nici Acestea sunlreprezenhbdc dilatarea aorteiascendentc
{>40
Tnstenozaaorticereumatismau, in primii ani de evolulie, mm)fi d€hiperrofiavcntricularn stangLrespeclivcrc$tcrca
atuncicendcalcilicrcavalvcicsteabsenta. dimensiunilorSIV ii PP (>ll severilarcsSAo liind
in schimb.calcilicrcavalvei.indeos€bi la bolnaviisub50 direclproporlionnhcu hipertroffa 'nm).
ventricularn (6g.23.29).
xni.csl..unscmnc.:nJc stenrzaaonic6.deregulasc\(:rir{tcJ . Dinrcrsiunilcdirstolicesi sislolicealcVS sLlDr nonnare
acesteia liind dircctJ)ropo4ionalA cu intensitateacalcilicrii. (sauscazutcprin hipcrtrofie$i hiperconlractilirrrc).
Cic$tcrca

fk ?J.2&SAo.Sectiuneparastemdl, axlung.lco M. Deschidere Fis.2J.29.SAo. Secllunepdr.sterula ax lurg. Eco M. HVS

sist,'lio!redu\Ari oalcilicrclalwldi. corcenlriclsecunda|i.
ll0 Ecogtdfia oftlului ti |dsebr.k la bazaini ii

dimensiunibrVS sugerenzd o insuficic'n1a aodca saumitrah in ceeace privc|lc c(iologia slenozcivahularc. in SAo
asociate.sau sndiul de insuficitnln cardiaci. r.Jrna.rnral aru(\r.r:r.(r,e< coB rati .c \pe(rn.e l n \\J
In ecogniia B se vizualizeazat dcschlderearedusaa va1 prinbicuspidieesrennpor{alrtAcaicularca indicelu' dc cxccn-
lelof aoticc in sis(o16, fira ca aceaslasapoatifi cuantificau. tfici(xte al inchid€rii diaslolicea signx)idclot un indicc dc
Sernrul ceI m.ii inportant estereprezcnlalde calcifiefeavaI cxcdrticitate mai marc dc l,l sugerind bicuspidia aofticn
\ . r1 .ri \h d . l t l0r . c . ues d g < n r/;.J .r. g J l r. p r< ./e n u .re n o/ei (fi g.23.32).Diagnosriculccfi de bicurtidic csteoferit de cco-
aoftice,mri pulin h varstnici. Se vizualizeaza, de asenrenea. fre/enl roo:ra J,n.d(usoe.re.p.\r i\
g.rl r.rB . car<e! i denl ra/.r
dilatareaao{cj $i hipefrofia ventricularastenga.Dh picaie o singuralinie de inchidcrevahulari h dissloli (fig 23 13)
planimetriaoriliciului aortic in sislolirpoale fi lar efectuatii Ecoeralia Doppler.Dlagnosticulpoziti\ al stenozeiaod'
> ,e a n u cu r J l. J / aLu : e\ (n l a l e aS A ,t (fi g .l l ..1 l l . c€ scclcclueazaj^nI)(. dc$rcceinDP, dltoritd velocililik)r
nra . aFre tenomenuldc rcpliere.

11&2lia licoJl. Ser( utc trnsl.Dil, & hrnS.\'r\o s0\ uunlrrenzi

er u r h o( lirper.eogcr.fnlerr (\rrgc!({). /.,& l J..l ?. S ce!r!r. prrr5rcfrrl i rr 1utr8.f:e(!V Inehrdcr e
c\cenncl (, Lrl )0\ o' br.(sftrl i .e i ci

Ii1,.lJ.J1.Eco B. Sccliuncplrasternaliax scurlsu\ siLuari.SAo lt&?J.JJ.f,co-8.scetiuleptu.stcaliux scultsussiturri.hdils[nn

cilcrncicu !izurlizareasupralclcilaLlei Ao in sistoli sccvjdcnlnviosinguilif icdcirchldete.\ o bicuspd,eaort,cri.

Un gradienrprcsionalsenrnificativ aparc]a suprafeleale
orillcixluiaortic< 1.5cmr.
AbordulDopplcrcstefi e apical5 canerc.lic supnsternaL.
Pentrudixgnosticnl stenozei aoiicesecorsidcrir semnificativ
un rEadienr sisldic pestet0 mmHg,sau20 mmHgin cazul
insu^licjcnlci
ao(iceasociate (fig.23.14).
In Doppl€rcolorseevidenliaza fiuxnlturbulentin aorta
ascendcnti. subfonni de mo^ic (1is.23.35). Este!til, in-
deoscbi. in depistareainsuficienleiaoticc asociate.
Scvcritateastenozei aodiceseclalucazipfin determra-
rcagradientului transvalvular Siprindct€rmimrea sxpralelci
3ll
ralvulare.determinarc crrc nupoarefi. dinpacatc.clcctuati
prin tlanimetriaoriliciuluiaofticin modulB ll ll.
Cradienrulval\Llar dclcmrnrat in DU,in acclcariaborduri
apicalsausxpnslcmal,sc referi atatLagradicntultransval,
vularnuxim catii la grldientultransvah,ular nrcoru. acesB
drn urni sugcrindo stenozisemnificativn cnnddepiwite
valoareade 50nrmHg,sauvaloarea de30 mnHg la bolnavii
cu insuficienFcardiaci.Dealtfel,aceas[vaharerepfezinii
limitapestecarcsc indici explorarea invrzivna bolnavilor
(fig.23.36)tl3l. la fel ca ii o velocitalcmaximaa flLuului
t|ansvah,ular>:lnr/s.

al&2J.J4 SccliuDe5 ounrclclplc0l. DC. (nadicnrrrarsld!u !f DC SAoti lAo (irddicrtsistolic

Fit,23.36, mediudc7(,nlnHg
Ao sjstolicdc ?7 nrmHg- SAo. jndicdndexpkrarca
hcnrodinfl
micilirvazi!1.

Suprafata sistolicea oriliciuluivalwlar poatcli dcteF

minataprin DP oombinatcu deterniftrcs suprafeleicdii
de ic$irca VS in sistoltr,in cco-B.Ilstc necesariadt dclcr,
minareavi(czcijcluluisistolicin caleadc ic$irca VS cAt9i
delermnrarca vitezeijetului;n dortadsocndenh (oceasladin
urmnin DC).Fomluladc dcternrinare, supralapioriliciului
aofiicestcSAo - V /V, x S,.undcVL:vclocitarea (Df) nr
crlcade ietife a VSr V,=!ck)cilaicain DC a curgcriinr Aoi
s snpralald cliidc ieiirea VS (ecoB)f20.2ll
Critcrii deseveritaEalcsL.nozciaotice sunrrcflezemrLcdc:
.velocilatc>4m/s
. gradientmaxnn> 70-80nnnHg
. gradienllncditr> 50 mnrHg
' \utrrblJ .'rihciUhriro||r ' n,, .1n 'Jerennrn.rr pr
ccualiade connnuilalc)
Ecogmli.rfi ccograliaDopplersuDlimportante$r in
F,&?J.J5. SeciiunesupiNrernali.DCo. llux Nrbnlenrin Ao unnnrirearezuliatelorlrakmcntuluichirurgicalindit'ercnl
ascendenri
- sAo (vczrcolorple$ 3) ci estevorbadc valvuloplastie, vah,'rrloromic
sxuprorczare
312 Icograha oftlului siwselar de Ia bdza ininii
valvulara. Un scmn imponani ai rezultatelor beneficeale Eriobgixrcumalisinala seia in considerarc indcoscbiin
tratam.Dtuluichirurgicaleslereprezentatde rcducerea,pe o cazulasocicrii stcnozei aorticesaustenozei mitralc(asociere
fe r ". Ji J r f . l! . J dI r . d n .n < fl ro h e!e indcoscbila scxullerrinin).
i n rri c J ' J rcs ri n e r i n
frecventar
cuul v{l!ublolnici ti val!uloplastiei esteimpofiantaredu- I)orim sa mcn{ionam$i lapiul ci insuficientr&|tica.
cerea sau. mri rq nomalizarca gradienlxlui indeosebiin asocicrccu sNnozamitralaestedescoridiag
transvaLwlar
I
I -ll. In cazul pnnczclor valv ulare existi pararnetri nosticaliexclusi!pfi ccogrslieDoppLer,.sclpend unui
specii ci
ai funcln)naliralidccstora(vczi cap.respectiv). exanren cliniccardiologic.dc rutina l22l.
Stenozaaortici subvslvulartr 8co-]l ii B.
Alatecografia M cetfi B lunrizeaziindeoseb I senrnern
Stenoza aoftica subvalvularn c! ii stcnoza aonicn supra- directedeinsuficienlir aorricat.in ccogl?lia M sepoateevrd.n
valvula€snfi cvasiexclusiv de natu* congcnitrla, dc accca rcspccti!llutterulsistolical
tia ii un semndirectimporrant.
clc sunrrelativrarirtalnitela vArstaadulln. lbilei antedoare a mitralci(fig.23.37), mairarflLLtter alfoilci
Nunevomreferila stenoza subaonicar dinamicl(crrdrcnno poslerioare, ai septuluisauil pcrctclriposterior[23].
paliahipenroficiobstuctivi). carcvafi expusnintr nnahcapibl.
in ambeletipurideecogmficscinrcsistreazideschjderea
In slenozaaortici subvalvularai prin diaiiagn libros sc in sistola.0rc$lcrea dimensiuniiridi-
amph a sigmoidelor
c\,idcnliazn, in eco-M,qi indeosebi in eco B, existenlaunor
cinii aonei(>40mm),cr€$terea dimcnsiunlidiasrolice a VS
ccouri,sinilare cu ecourileprodusede valveleaonice,in cu conlractilitate crescuti(atattimp cal nu aparclcl), incal
.rll'.rJ( rLiiir.d \ S.la oisranlide \ alreleaortrce. i cal Je
dimensiunile sistoliceal€VS suntcvasnronnale.
stnoza fibronusculartr seevidenliazn ingustarea semnilica- O dimensiune diastolicda VS lntrc 60-70mmtlg suge-
rivl a cniidcicflrcaVS. rcaz6o insuficienFaortrctr degradmic,intrc70-80mmHgo
in cco-Doppler colorrurbulenla este!izualizatir^ncalea IAo dc gradmare,iarp$te 80 mmHgs gcrc&ze, deregula.
de ic$ircaVS, subvalveleaortice(aspeclulmozaic). instalarea insullcienleicardiace(cordnriopalic),riscul in-
Dctcrminarca gradientului transstenotic estesimilaracu lcrvcnlreichirurgicale fiind mult crcscul1241.
ceadin stcnoza lorlicdvalvulari.iarulilizafeaI)Pprecizeazn Un aspecl particrlarseinregistreazA in irsuJicicnta aorlicil
cxistcnlrobslacoluluila nivel subvalvulaf,eexistAnd gra-
Acutilin caresenoteazl.in eco-M,inchidcr$prccocc a vaiver
dientr'ntrc rcgiuncusubvalvulard ti supravalvu larl (gradienl
mitralc(abscn(a undeiA).iardimensiunilc diastolicc aleVS
tmnsvrlvulsr).Accst0 liiDdinschinbprezentinlrccanrerade suntnonnalcsauu$orcrescute (dilatnrca VS scrcalizcazil^n
umplcrca VS ti rcgiurcasubvolvuhra. timp)(1is.23.3u).
Stenozasortict suprsvalrularll Estcifirportanlidetefrninarea in cco-M.si indcoscbiiri
Iislc r.rri fi ca podtcll evidentiatidoardc ecogrAli$ii cco-B. a liaclici de ejeclie a lentriculului sl6ng.Iiaclic dc
clcclic obligalffiu ..supernornala" irr insuticicnt{ orlrcl
lo eco-ll se evldcnliaziingustarcN Ao ascendcn(e, ln
distanltr dc sign$idclcaortei.
(i rndielllultransslenotic sedetcmrinn srmil roudclcnrF
:1rer drnSAnr:rl\ultrrir. in DC.
Dopplcr-u I colorevidentiaz6 turbulenF(asfcclulmoz.ric )
la distanFd€signroidele aorticc.irr ulilizare0DPprecize0zl
absenla gradicnlului LrNnsvalvular ti pfezenfa acestui gradrent
intrc rcgiunea sitrain imediat deasutra sigmoidclor Norticc

Insuficicn(a aortictr
lnsuficient.raorticd.nr um1ncu cntevadecenii,de cele
maimulteori. dectiologicrcutnaftl1lala, estela oraactuala
dominantde etiologiedcgcncradva $i tunctlonah.
Apar€indeosebil.r indivizii vrirstnici,prin dilaiarearn-
dicinii aortei(ineh aoric), ca umrarca aterosclerozei aoF
lrce.saua hipertensiuniiarlerialc.La vArstndnnrddilaiarea
radnciniiaorteiprin boli de sistem(sindromMarlhn.etc.) ai&LJZ SccJruDc parlstcnrahax lung.Eco M. Flut*sisrolic il
Icprerinii unadintreeliologiilefrccvcntindhlite. VMA $iVMI, - semndirecrde LAo
 313

ris.2.r.J& Secliurc parastern!ldar lung. Eco M. irlchtdcre

p.ccocca VM caru.tcristici.IAo .cuti.
diaslolica
Frs.2J.J9.Secltrrnctarasremnlrux lung.DCoin modulMin catea
,1<r()i r( vs i me,Irr.uh \A o. \rl ,' . i trr( | F.o t r r rm , '/ di(car c
-
falainsulicienticardiacn. inrcgistmrearmcifraclij deeiecllc ccrtilicdIAo (sigcata)(!e/ico]o plaDt.3).
insprclimhainferioar6 a normaluluisugcrcaza dejaaparilia
corduluimiopatic(insulicicntlcardiace) SiimpunedeurgcnlA
explorarea hemodidamicl invazjvd.
O valoaresimilari.dar mai redusi,o are deteminarca
DTSVScare,in cazuldcpliirii valoridc 55 mm.sugercazl
deprimrreafunc{ieisislolicc$i ilnpuncrcceagiexplorarc
hcmodinamicA invazivi urgenti.
EcogrsliaDoppl€r.RcpreTintd ncrodrceamaiacuraGin
dcpislarea 9ievaluarc{ insuffcienleiaorri0c, deInuheoriliind
dcpistate mici icluridc lAo la bolnnviila cAre.celputir Ia o
cxaminaredcrulini.nusedepislcaztr sufluri diastolicconicc.
DiaSnosriculpozitiv al lAo scpo tc facealAlin DP.D(:
cit Si.indeosebi. in Dft).
ln I)Co exaniMrcr sc poatelhcclic in paraslemal rxl
lungl. catti in 5 clmcreapical.cupld cu FlCc.
In ambeleincidcnlcscevidenli0z,lirciljeruldercgurgrtn-
rc in caleadeiciirc AVS.Esredeoscbil dc util eco-DopplcFul
co or in InodJlVJ r.'pennire. chidr)rNrsornelor ncr\ i,,ule. l.i&?J..raSectiunc
apicah5 cunrercDP Vebci(drc
dirlstolical
poznlll- djagnosric
penrrulAo.
vrzunlizueanozaiculuidiasiolicir oalende ie$irc{ VS (in
parasr€roal axalungr)(fis.21.39).
ln DPii DC (5 camereapical) sccvidenliazlo vck'cir.rte Utiliz.rrea DPs.ruDC in combioa Iic cu ecog$ti.r! (pen-
diastolicIpozilivi oareconfinnl diagrosticuldeinsulicicnla lru calcularea debiLuluiaorticti dcbituluinirrt). pcrmite
aoltici (lig.21.10). cdcLrlarea iiactici dc regurgitare.
IAo fiind considcratarde
Severitabrinsuficienleiaoiicc poare1leslilnariir toare gladmic(lejera)in cazuluneiFRs'rb40%ii sevcrnin ca^rL
cele rrei nloduride exxminarcDoppler Dinlrc nruitiplele unci I:R p€ste60'/0.
nrodalifiri.lc cvaluare.!onexpuncdoarcArela. In practicl,ccamai rapidi evaluareI seledrnliilAo se
Astfel,iI DopplerconiinuucsteimponanLlcatcutarea obLnrc prir Dopplcrcolor
PHT-xhricarc.atuncicind ltrc v.rlorisub800ms pledeazn Utilizandsccliunea parasremal
rxarlungl ti dcrcm narea.
pentruo fraclieregurgitanis pcstc40%,sxb600mspennuo in n$Jul\4.r nrdanii lelrlr dc | \,, l or g ne lA.,L<cor,r-
tiacliercgurgitardpesie50%si sub400nN pcnrruo fraclie dcri degradI cindjetulesre < 8 mm.deg|adII intrc8-t2 nml
regxrgilant,pesre60%[25]. dc grad lll intrc I2-16nll| $rdcgradlV > l6 nrm(fig.234t )
 E.olrdlt1|otlul1ri ti ra ,1.r de ld hdzd inn,ii

F,&?J,J?.I)(i) 5 cnNLe rpiexl.lclocrtaicdilsdicii nn)/nrcore

Itrr2J.lt. Secliune a\ hug DCoif nuld M Jcxrlli
tftNsremali depi i ei rc1,: r S Iv l A o grrdl rl (vcl l coknnl .ni al )
oriSfe l0 Dxn 1Aonrcdic(!c7icol(rtlnn ])

ln 5 carnefe apic!l(dartiinp{rastcmllaxa lunga)l^osc R edi rr i rrtabel ul21.4.cri tcri i l cdc cval unreal e1A odup.
consideddegradI cnndrcgrgitarcacsrccxcluslvin caleadc recurnJ| l d:r-is.,(|
l < cri ,l iA r rnl I(.urJ JJ I roJ.rrdroC rr lie.
ieiire a VS (subsis,noidiani), dc sradII candaiun-qcpar.la in tratarnennrlinsuficicntciaor(icc,prolczarefl\'alvulalil
112dinseptulinlervcnh iculargra.lIII cllnddcpiiclN accosli cstc sirgum solulie viabilii. fiind rccomrndtl a seetechn cn
valoare ii srrd IV catrd 4ongela apcxulVS(lig.23.12). prolczc nrccanice(nrai rczistentc).sr bl(togrcc (indcosebl
in stlieil.o |l]erlxhnr.rilrborio{snraDo(cr1i.in prr stcF h l cmci i nri rnpnI acri vi ti l i i honnon{l c).Mcnl i uri rr ti lhf lul
nalaxscurt,sLrpmi'ata jctuluil. originch supr{hlrcrmcrcidc ci sc!critrlca Irsullcierrleiflorticecslcsubcstim{ullr bol)av ii
ictirc a VS.Aluncicrind,rccsi ftporl cslcr 4%'ltlclra rcgur- cu slcnozi nrilralll concon)ilenti.drn)ritarrcduccriidcbilu[]i
gilrnlaeslcsLrbl5'%.( Andrapot lcstcnrlro4-25%li cti{ si sl (ti caorl i c.D c acccal n subi ecticu i stcno/I nl i (r' {lii.n) '
rcgurgrl0nra esreirrtfel5-30".1,Un rafor 25'50'/,plcdcrzfr sul i ci cnl 0norl i ci 1. cl i i 0r Ini orI. ncccsi t:dc rcgul r cor cclic
pcntruo liaclicrcg ryilrnrtilintfc30-50%.larunrrportr'50% chi ruryi cl i radi cal l(prol l e?0rc vrl vul ara)[I31.
plcdcazi pcnlruo liocliercgu|giirftlNstc50%.

7lr1l?.tL Pf rf'!tri calj( ar j\ iii er t r ! 1. ( i! i ulr lilili pc r ( r u e ! ! l u r ! c ! \N c,i l i l i i i rnLn0i u\ciN l cc({ h| i 1l :)

t \ R,\N,lLlt{l sLl{ c tL R A I
\ lic.vunL(lrl{Lnl
m$ar rd nxlLsxtr(l.lccL(l. c.rftnr.

lr\R , \NltlRll ln )PPLI R

. liirS nrx..tr']tr,ir L \'()Ll) ( ( ' r c Ll . t s I r , a : i r r . \ . c n t [ \ r 'r b r

r u \ e r \h o l , r L , r n,.r . l L o . r r r d r

P lRA\'lllR (A\|L At \ r
. . rlrn r cn LL Iriliirlrr.r l\ O l
. r [ . Lo * 5 .rl'.trr.r ]ctr 0r I r . r ! \ i

. \ rltrnru Lrrg tr,gtr.rLjnb x i. r

. l,r.tr d. !!grr!trx'.l"i,)
. rf r dni.,trltrlJ.!trl!natrr.L.rl! (.nirl
 3r 5
Stenozapulmonard
Ne vom referiin primulrandh stenoza pulmonafival-
vularl careeste,in majoritatea
covariitoarea cazurilorde

Esteintahid indeosebi la copii,darscnurnlrl $i printre

cardiopatiile
cong€nitale{valvulopaliile congcnitalc)cclmai
desnotatela varslaadulti, in tuncfe de severitateaacesteis
In eco-M semnuldirectprincipal,Si cvasisingular, de
slcnoza pulmonarlvalvularlestecre$terea amplitudinii
undei
"a" aecogrameipulmonarecarealingcsaudeplicste 33%din
amplitudinea deschideriivalveipulmonare (fi9.23.43).
In eco-Bnu dispunemde semnedirecte,dar, de regula,
valvapulmonarA areecogenicitate crescutiti sevizualizeazd
diminuarea mobilhAliisalesi$tolice ll3l.

r'rk2].l4 SP.Scdnllc p3raslcrnalld scurtsussitutrri.DCo.Veloci-

delipmozaicinlrunchiulp(lhonlr(vrri colf pl.n|. 4).
tatcsistoljca

riia23.l.tSeclnmcl]!rusler{Ulax
seunhl(rM.tlndu'adcunlnlitu.
diDchuhcrcscuu! pcnku
cnrtcr$isricl ncroz&prhomd!01!ulal

fi&2.t4t SPScctiunc p'rr0stemnli

llxscunsussituati.D(: Cndi-
Atdiirreco-Mclt $iin eco-B(examinare in rx paraslernal enl tinsvnlvuldrdel5 mmllgconlirm6nd SPvtlvuldrd.
\curtsussilrrti) scvizualizc.rzii
criscmnindir€ctoresi€rea di-
mcnsiunibraft rcipulmonarc. carcdef,aiegc diametrul oonei.
lco-Dopplcrrcprczintiprircipslulmijlocde diagnostic l,l in IX iru l)P se detenninisr \e\enrJrerrcno/el
al stcnozcipulmon.rrc valvulrre.cxaminarea fiind ftcuti in puhnonare, un gradi€ntmaximpeste40lrnnolbrindindicrlia
sccliuncparastcrnaU.rx scurtslrssiturti. tratamcntului iDt€rvenlional sau,mai rar.chirurgical.
irrDCosevizualizeazi mozaicin irunchiulad€rcipulmo- La oraactualerezolvareatempeutic[a sienozeipulmonare
nare(fis.:3.,{4),iarin I)PsauI)C sevi^alizeazlo velocxate sc efectueazicvasiexclusiv prin valvuloplastiecu balona$
sistolici n€gati\danrpla.pudnd fi determinatgradientul (dilatare), rezultatel€fiindsuperioaieintenenlieichirurgicalc
transvah,ular. Un gradientlransvalvular p€stel0 mm este (valvulotomie) carede reguli,rezultdin insulicienFpulno-
considerat diagrosticpentruprez€nlast€nozeipulmonare nar6restantr,cu cons€clnlehemodinamiccimporl}nE.
valrulare(ilr absenla candgradientul
runturilorstg.-dr.. tre- Stenoza pulmonadsubvalvularl.musculartr, eslegreu
bui€ se deprteasce20 mmHg pentu a fi diagnosticpentru d€ diagnosticat p n ecogralie, senneledireclefiind abscnlc
sP) (fig.23.a5). in ecograliaM, iar in ecograliaB evidenliindu-seingus[rca
316 la.ograkd coftluht nrtk,- ;1.tlu htzd inirnil

caii de ictirc a \iD, tu secliunctarasternah aa,t scunit, sus

situ.rli. In dmbelemoduri ecograficcsepoateviTualiTahipcr
Ifofia rl)ntriculari dreapta9ie!cntual mtuireadimensiunilor
vD lintr uD sladlu avansal).
Insuficien!apulmonari
pulrnonad
nrsuiicicn(a
ClaSi inruficicnl{lricuspidiana
csle.plactic.in t(ialitatcacaarrilordeorigincl unclionali.Ea
apareinhipefcnsiuncapullnomra. dar$iin cazunledesteno'
zirpull1)onari reTolvltnpdn !alvulotomic(+!al!uloplastie).
in generalinsuficicnlapulmonari semnificit o IITP severi,
nromcntin carefezolvrrcachirurgicalia valvulo|aliilorsau
afccliunilo.cal diacealc ininrils1angi caredcicrmrnai xpanlra
in$rficicnleipulmonare cstc,dc multeori. defniitn.
Eco-M qi tl nu furnizcrzl semnedirectcsauindirccle
de nrsulicicnl:pnlnronari.Dcsigut ea poatefi bnnnilain
prezcnlxunoralecliunialc ininlii slangicareevolucazicu tig.23.17.tP.scc{iureparastcnalidx scurl DC. Vclocitale
hjperlcnsiunc puLmonad (SM.ctc.)ii in caleVl) eslemairil lP
tozili!i. caractcdsiicn
diastolici
devoh,n1. consecnrFpfobabih r IITP iia lPcorseculivc f261.
l)iagnos(icul acuratal ll'$i cvalunrea severitAtii
salcsc
efectuc{zlprin eco-Doppler. Dft) (sccliuneparasternah vclocilatein t)C sanDP sub2 m/spoatcil nrdhlld la 18%
scurlrussiluata)oieremdiagnostic ilcil ti rapid,evidenfii^x
d urnrr(normJlir' lr 50'. drnrrenormrlrrrn.ri.ln "chrmh
flux retrogr{ddiaslolicin calerdc icfirc a VD. d€ culoarc tlrrtrnderca pe lunEl.lNrAnlid jer.rlJr,'1,'rdc tegtrryitJr.
roiie saumozaic(fig.23.46). in calcade ietirea VD. sauvclociutide pcslc2 r/s (in DC)
In l)C snuDP,cuprobasitll.ltar'nVD i ediatsubsigmoi- plcdcuzd pmffr lPseverl.dcrcgulr,secrindArn IITP Dcosebit
delepulnnrrarc. scc!identiaTn vclocilstcdiflslolicipoTiti!A dc ilnportanl, din detc ninArcugradientului dirstolicAP"VD
careasigur[.dc {sclllcr)ca. diagnosticul (1ig.23.4?). scpoatccstirnavaloarea ap()xinralivla PAPD, a\'indin ve-
SevefivilcsIP porlc li evaluAtlirr l(xttccclc rei Inoduri derccnprcsiuneadiasolicI mcdicin VD estcdc uproxifiatv
Doppl<r. li mmllg. DesigurcalculclcdcviD€ronalein clt/ul uperi(iei
Trcbuicnrcnliordcilo IPdeInicl irtcnsitate ffuxcolor insulioicDlci VD. c6ndPTDVDcstecrescull[28]
rmcdiatsubvAlvclcpulmonarcin crlcAdc iciirc o VD. cu Scpo lc dcterrnina deascmcncn PAP(carccslccgnli cu
3M - 2l) ir carcM=4vr(vekrcilnlcA prolodiastolion) + lt). rtr
D-4vr(vclocitulca lclcdiasrolicn)+ 10.Dcasernener poatcli
esrirnrtii PAP)- D PTDVT) (rprox.l2nnllg)
Rezolvrrcalcrapculictr a insulicicnlcipulnonnrenu sc
cl-ecluenza. dc rcgulli,prionranopcrc intcrvcr\liorrrlesouchi-
rurgicalespccificc. inrulicicolapuInn)|r3raircclucdlrdu-sc sau
dispirinddupi corcclid alcclirnilorc roru cruzat-o ll3l.
in tabehrl 21.5.sunlrcliatecriteriilcdc cvrlurrealeseveri-
tartii;rsulicienteipulmonrc ir coulbrnr ilatccurccornandnrile
SocictiliiArnerican c dc [cocarrlioglritic.

Bibliografie

i.Wdg A. Hinlnri K, Brshore TV. Rran t (orelxlron bel$cer

qmtrtitahreleli dlria spontrncous cchocrrdDgrafh. connr{ xn'lnr
fis.2J.lrt. Il'. Seclndepdlsrcmalaa\ \curL.DCo fhx diastolc Licr ibr rogcn lc\cls in nilr.l sLcnosisJ An So. F,c[oclrdiograll.v
rx,z.i. nr calcadc icrircd VD (!e2icolorpl.n$ 4). 2 0 0 1 ; . 1 : 1 8159 l
 lt7
qi Doptlerutilizalipenlrueraluarea
Idr., ?.tt laranebil ecocardioSranci (dupall).
ptrlmonare
sevenLliii,rstrncicnlei

N
Aprccicrca crxlui dc rcgnraildc in Dco
r todlc xvdadurxriscuii
jetLfuiri duralallsrf ului dc
DensilalEd

. nur diasloliccarese&mnriprecoce
tlux srltolic Nlhonrr conFraLiv.!

2 Haile LK Appleton cl lopp RL. Dilirentialion ol conslfldrle vula!Regngittionwith T*o-dinrnsional lnd DooplcrEchocardiog-
pedorditis dhd resbictile oldiomyopthy by Doptler echdlidiog- dthy. JAh SocHcochrdioer 200117:778-?99
r.pht Cnculario. l9E9t?9:35t-?0. lll Bono$RO,Cambcllo B, dc LA Jr EdnruidsLH J., rcddcrlyBJ.
3 Aranthsubnrnoian K, Iycr C, Karthikcyanv Ciant lcft alrium FreedMD. e(trl.Cuidclincs lorlhc nranlgcmcntofldtichts *ilh lal
se.onlury to tighl bilral srenosisleddinglo ncauiiedLulqnb&he! vuld heartdisclse:ei.ootive summaryt a reportofdN Am$icanCol
syndfomcr csc rcporl with dnl'hdsisoD rolc of .ohocddiogrdphy legeof Cardiology/Anelicd Hert Association TashForocon |ru.-
in a$essfreit ofl.utcmbachfi syidfonc.I Am So. Ecocardiogtuphy licc Ouidelins(Comillee onNtmeemmtollilienls wilh Vtrlvuld
20 01 i10 :10 33- 1035 l]cln Discds€). (.ncuhrionl99Ei981949-E4.
4 Cdc! N, Dcmirb{gR. Ozhn C, ElyonucuB, Guns A, €l al. Clini l4.SinghJP.EvunsJC,ehyD, Lu$onMC, FreedLA.IullqDL.etul.
cdlaid cchocsrdiographic prcdictos of lclt dfiuldppcndAgedyslunc Pre!aknc€and clinicaldet€minontsolmitrallricuspid, mdnodicrcguF
tion in pdti.ntswith mitralstcnoshin sin$ d'ythm.JAm SocEcocaF girdtion (thcIhm ingham llcanStudy). Am.rCardol I 999r83:89?-902.
diogaphy 2004:Er8l9-E23. l5.WallerBF, HowardJ,Fss S.Ptahology oltriou$pid vullesicno$s
5 AUanJJ,LevisJ. Ke!b* RE Echoc{diosaphio Qudlirrfion of Mi andfulcricuspidiegurgitation-pln III (llii C0rdioll995ilN:225-30.
tml Rcgirgitation:A Ncw Doppl$Tcohniquc.JAm SocEchoourdiog. l6.SbuplAY. Posnc!A.WuEclM. VutuliM.Sdgic Evuludtion of
r0p byl99 Ei2; 149- 151. lricuspid reguryitdlion selelity:eohooudiosraphi0 rDdcliniculoonc-
6 SugieA, Freila N, Chen MH. Mrr$hall JE. weytuan49, Roberl l dti onJ A ' n S occchoc3di o$ l 998i l l 652-9
AL. Echocsdn,graphio Nsessme ol milrdl slenosisand ils associ lT.TibouilbyCM. nn qucz.SraDo l\.1,BrilcyKR,T6jikAJ,Scward
atcdvalvuhr lcsionsin 205I'eticntsundldckofs$oiatiol with millal .rd.Quditificdrion ofrdc$pi(l resursiruion by me{surins rhc wid$
vrllc pirtapsc.J Am Socllchochdiogmphy1997i2:141-148 ofrhcvcn6contrlct0 with Dopphrcolo!ffoa mlgingrdclinicasntdy.
J Am CollC&liol 2000i36 r472-li
I Che! CG, Thona$ JI), AnconindJ, Hdrigln P. Mucllcr l-, Picafd
MII. er rl. Itrpol of nlpingtug wollicl on color Dopplerquanrincr- l8.Shivcly BK. Chdrlton GA, C6wfod \,1H.CrhaicyRK. f low dc-
tion ofnritmLrcgurgititin. CilorldtnD 1991i84?12-20 DendcDce oivuhcurorin Nrtic stoosisrrclutbn io valvcnn)ll'hology.
.l i h (b (ddj ol l 998i .l l 1654-660
8.QtriN cs MA, Oiio CM. S$dd6rd 14, wdSgoncrA. Zoglbi W .
RccoDne .rions lor qumrlnclrid' of r)oppl$ cchocardiogfrphy: . l9.ArscDluh M.l\1sari \. MaBniC,YaoJ.I)cras1..Pand!n N. !hfi-
rcpolt tioN rho Dopplcl QuolilicnLiouToskFo(e ol Lhc\one.clF tlion of u{LoDic vllvc urcrduiry etecrio!i! pr iqns silh !4lvulu
turc and StarsardsComDittccofllle Arqio!! Soqcly ofEcln,oa i- ioltic slcnosis suluntedb, tsoiirhsslonrl cchocadiognp ric nl.r-
oSn ph y..rANSlc lic hoc ar dlogr 1002il5 16784
iNciryicorlprlisD $ith tladilnDrlDopplqdat{.I Am (oll (lndid
9.Ro $iA.Go ir C, ( i. s t ir ir i( i, Pr loliM A. Ans c ltr 'i MZ. a f d i i P l , c 1 l
ulrirl lilhrg lolLnnecm be usd 10reliibly esrinde the regrgilrnl
lo.Dccrof(ai. shafdasR. valdclcroz 1..Araysisofd'c.ifccl of
iow i.le on UrcDopplercontnruily cqulrionlbr stcnotic oriliceurcr
volum. in .nrr.l rcgurgiulion J Am (oll Crrdiol l')tt:l}212-?.
cal cl l ari oiai
s dneri ol sl l LdlC i rcul al i or
l ' r98i 9 7: 1591'1605
lo.Mclc l). Vandcro.d q Pdbcios I, Rivo! IM. Dinenorc R!.
2l.Car!i! D. DumcsnilLC. Duand LC, KddcnL. Pibrbt P Dis'
schw.me.fi.lr, et!1. l}o{i'na jcr sizcby l)onfl$colorflow min
dcpuciesbelween crtherer.Dd Dopplcrcslrnrnles ol vulleelleclivc
tnrgpredictsselerly ol nnllul reSurgna[oniclinic.Lsludr€s.Citul& or ficcarc!cai bepredicted iror drepres{rcrecovery phenoncnon:
pr&lc{t inplioltnnNwirh rcg!ftIquanlilicatnnr ofiorlic srcnorsse-
ll.Hall SA, BrickDcfMl, Willcn DL. lrani UrN. ,\liidi l. Craybu r lerty. I Am CollCnrdiol:003141:415-41:.
tA AssnssnenL of.iiril regurgirariodscverity by l)ofnler coLor 22.Taylor,^L, lichhornll.l,urickncrMl. tibc rafiRS,Graybuni l,^
flow nupping oflhc vennconrach.Cicuhdon 199?;95:61642. Aorticvulvemorphology rn mporl.Dln vitrodelemindnt orprox!
l2.ZoghbiWA.Enriquez-Sar.no M, FoslerE, GraybumPA.Krdft CD. nal regurgnanl iel widfi by Dopplercolorflowb.pphg. J An coll
for [valuation of lhc Scvcriiyof Naiivc Val-
et aL.Reconmentadions Cardioll990il6:405-12