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Insufficienza aortica

Insufficienza aortica.

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Insufficienza aortica

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  1. Insufficienza aortica

  2. The aortic root may be defined as the portion of the aorta that supports the leaflets of the aortic valve, delineated superiorly by the sino-tubular junction or ridge (STJ) and inferiorly by the aorta-ventricular junction (AVJ). It comprises the sinuses, the leaflets, the commissures, and the interleaflet triangles Giunzione sinotubulare Cuspidi Commissure Triangoli tra le cuspidi Seni di Valsalva Functional aortic anulus “Annulus” The aortic root: structure, function, and surgical reconstruction. M J Underwood, Heart 2000

  3. AORTIC VALVE: ANATOMY FAA: functional aortic anulus

  4. Mechanism of Aortic Regurgitation Valvular disease Aortic root disease

  5. Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures G. El Khoury, Curr Probl Cardiol 2005

  6. Mechanism of Aortic Regurgitation Functional Anatomy of Aortic Regurgitation Accuracy, Prediction of Surgical Repairability, and Outcome Implications of Transesophageal Echocardiography. Circulation. 2007, le Polain de Waroux JB

  7. Aorta normale e Ao ectasica mancata coaptazione

  8. Ascendente Seni di valsalva Ginzione ST Anulus VSn 2 cm 2 cm 2 cm

  9. Cusp prolapse or fenestration

  10. Poor cusp prolapse or fenestration

  11. Poor retraction and thickening Diastole Sistole

  12. Gravità dell’insufficienza • Anatomia funzionale • Doppler • Ventricolo e atrio sinistro • Pressione polmonare, ventricolo destro

  13. AO flow reversal Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER Flow disturbance (jet size) Vena contracta PISA

  14. AO flow reversal Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER Flow disturbance (jet size) Vena contracta PISA

  15. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER:JET SIZEparasternale asse lungo

  16. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER:JET SIZEparasternale asse lungo

  17. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER:JET SIZEparasternale asse corto

  18. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER:JET SIZEparasternale asse corto

  19. Evaluation of aortic insufficiency by Doppler color flow mapping.Perry GJ, JACC 1987 The color Doppler echocardiographic studies and aortic angiograms of all patients who had these procedures performed within 2 weeks of each other between October 1984 and August 1985 were reviewed to determine whether any parameters of the regurgitant jet visualized by color Doppler study predicted the severity of aortic insufficiency as assessed by angiographic grading. Patients with an aortic valve prosthesis were excluded. Twenty-nine patients had aortic insufficiency and had adequate color Doppler studies for analysis. The mean time between color Doppler examination and angiography was 2.3 days (range 0 to 12). The maximal length and area of the regurgitant jet were poorly predictive of the angiographic grade of aortic insufficiency.The short-axis area of the regurgitant jet from the parasternal short-axis view at the level of the high left ventricular outflow tract relative to the short-axis area of the left ventricular outflow tract at the same location best predicted angiographic grade, correctly classifying 23 of 24 patients.However, the jet could be seen from this view in only 24 of the 29 patients. The height of the regurgitant jet relative to left ventricular outflow tract height measured from the parasternal long-axis view just beneath the aortic valve correctly classified 23 of the 29 patients. Mitral stenosis or valve prosthesis, which was present in 10 patients, did not interfere with the diagnosis or quantitation of aortic insufficiency by these methods

  20. Evaluation of aortic insufficiency by Doppler color flow mapping.Perry GJ, JACC 1987 “The short-axis area of the regurgitant jet from the parasternal short-axis view at the level of the high left ventricular outflow tract relative to the short-axis area of the left ventricular outflow tract at the same location best predicted angiographic grade, correctly classifying 23 of 24 patients”

  21. AO flow reversal Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER Flow disturbance (jet size) Vena contracta PISA

  22. AO flow reversal Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER PISA Flow disturbance (jet size) Flow disturbance (jet size) Vena contracta

  23. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLERPISA (Proximal Isovelocity Surface Area) r PISA

  24. r PISA Flusso istantaneo = 2r2 * va (2r2 = Area PISA, va = velocità aliasing): 6,28 * (0.8 * 0.8) * 34 = 137 ml/sec Orifizio di rigurgito = flusso istantaneo / velocità: 137 ml/sec / 400 cm/sec = 0.34 cmq Volume di rigurgito = orifizio di rigurgito * integrale di velocità: 0.34 cmq * 165 cm = 54 ml

  25. Application of the Proximal Flow Convergence Method to calculate the Effective Regurgitant Orifice Area in Aortic Regurgitation r PISA Trimbouilloi CM (JACC 1998)

  26. Application of the Proximal Flow Convergence Method to calculate the Effective Regurgitant Orifice Area in Aortic Regurgitation Trimbouilloi CM (JACC 1998)

  27. AO flow reversal Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER PISA Flow disturbance (jet size) Flow disturbance (jet size) Vena contracta

  28. AO flow reversal Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER Flow disturbance (jet size) Vena contracta PISA

  29. Zona di convergenza flusso laminare che converge verso l’orifizio Zona post stenotica flusso turbolento Vena contracta VC: il colletto più stretto del flusso di rigurgito, subito al di sotto della regione di convergenza in proto-meso diastole.

  30. AO flow reversal Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER Flow disturbance (jet size) Vena contracta PISA

  31. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER AO flow reversal Flow disturbance (jet size) Vena contracta PISA

  32. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER:Aortic flow reversal Severa Lieve

  33. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER:Aortic flow reversal An end-diastolic flow velocity > 20 cm/s is indicative of severe AR

  34. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER AO flow reversal Flow disturbance (jet size) Vena contracta PISA

  35. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER AO flow reversal CW:PHT Flow disturbance (jet size) Vena contracta PISA

  36. Metodi per quantizzare l’insufficienza aortica Doppler continuo:pressure half time (PHT)

  37. INSUFFICIENZA AORTICADoppler continuo

  38. INSUFFICIENZA AORTICA: Doppler continuo Lieve Rilevante

  39. INSUFFICIENZA AORTICA: Doppler continuo Lieve Rilevante

  40. INSUFFICIENZA AORTICA: Doppler continuo Influenzato dalla pressione diastolica ventricolare (funzione diastolica) Lieve Rilevante

  41. Metodi per quantizzare l’insufficienza aorticaCOLOR DOPPLER AO flow reversal CW:PHT Flow disturbance (jet size) Vena contracta PISA

  42. Gravità dell’insufficienza • Anatomia funzionale • Doppler • Ventricolo e atrio sinistro • Pressione polmonare, ventricolo destro

  43. Aortic regurgitation severity(ASE - 2003; ACC/AHA Guidelines for Valvular Heart Disease – 2006)

  44. Camere cardiache Insufficienza aortica severa DTD > 80 mm, TS > 55 mm (25 mm/mq), VTS > 45 ml/mq; FE < 50%

  45. Physiologic framework for assessing preoperative predictors of surgical outcome in chronic aortic regurgitation

  46. Schema for selecting asymptomatic patients with aortic regurgitation for AVR Borer JS, Bonow RO Circulation. 2003

  47. (ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease – 2006) Insufficienza aortica severa

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