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Inima tricamerala

Inima tricamerala. Aurelian Cosmin Diaconu Clinica de Medicina Interna si Cardiologie Spitalul Clinic Coltea. Motivele internarii. Pacienta P.I., in varsta de 30 ani, se prezinta pentru: Tuse cu expectoratie muco-purulenta, febra, frison si dispnee inspiratorie. Istoric.

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Inima tricamerala

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  1. Inima tricamerala Aurelian Cosmin Diaconu Clinica de Medicina Interna si Cardiologie Spitalul Clinic Coltea

  2. Motivele internarii Pacienta P.I., in varsta de 30 ani, se prezinta pentru: • Tuse cu expectoratie muco-purulenta, febra, frison si dispnee inspiratorie

  3. Istoric • Diagnosticata de la nastere cu canal atriventricular comun tip incomplet si situs inversus abdominal. • Familia a refuzat interventia chirurgicala. • In urma cu 3 luni, a fost diagnosticata cu chisturi de ovar, pentru care a urmat tratament cu contraceptive orale.

  4. Examen clinic la internare • Hipotrofie staturo-ponderala • Cianoza de tip central • Hipocratism digital • Jugulare turgescente • Pulmonar: raluri subcrepitante bazal dreapta; SaO2=86% fara oxigenoterapie. • Suflu sistolic localizat precordial • T.A.= 110/60mmHg • A.V.=86b/min regulat

  5. Diagnostic de etapa • Canal atrioventricul comun tip incomplet • Insuficienta mitrala • Insuficienta tricuspidiana • Infectie pulmonara acuta • Situs inversus abdominal • Chisturi de ovar

  6. Biologic la internare • Hemoleucograma evidentiaza: - trombocitopenie 109*10l³/uL - poliglobulie cu o hemoglobina de 19.8g/dl. • CRP 6.6mg/dl

  7. Electrocardiograma la internare

  8. Radiografia cord-pulmon

  9. Ecografia cardiaca transtoracica • SIV 13mm, VS 39mm, PP 10mm,VD 46mm, perete liber 12mm, AP 38mm, • Atriu unic: diametru transvers de 75mm • Insuficienta mitrala excentrica moderata prin cleft de valva mitrala anterioara • Insuficienta tricuspidiana excentrica severa: gradient VD-AD=106mmHg • Posibil solutie de continuitate la nivelul septului interventricular membranos, cu sunt bidirectional • SIV aplatizat sistolo-diastolic catre VS, FE 55%. • VCI 25mm cu minim colaps inspirator.

  10. Ecografia abdominala • Ficat: lob drept de 6cm, lob stang de 14cm • Splina in spatiul Traube, cu un ax lung de 9cm • La nivelul ovarului drept formatiuni chistice, dintre care cea mai mare de 4-5cm.

  11. Diagnostic diferential • Trombembolismpulmonarsuprainfectat -pro: poliglobulie, tratament cu contraceptive orale, absentatratamentului anticoagulant in istoric -contra (?): D-dimeriinegativi • Infectiepulmonaraacuta -pro: hipertensiunepulmonarasevera, imunodepresia , simptomatologia -contra (?): lipsaelementelorradiografice

  12. Diagnostic final • Insuficienta cardiaca clasa III NYHA • Canal atrioventricular comun tip incomplet • Insuficienta mitrala excentrica moderata prin cleft de valva mitrala anterioara. • Hipertensiune arteriala pulmonara severa • Insuficienta tricuspidiana severa • Posibil DSV membranos • Poliglobulie secundara • Trombofilie – Sindrom antifosfolipidic • Situs inversus abdominal • Infectie pulmonara acuta • Formatiuni chistice ovar drept

  13. Tratament • Regim igieno-dietetic hiposodat. • Vaccinare periodica (vaccinarea antigripala si antipneumococica) • Profilaxia endocarditei • Tratamentul medical: • tratamentul insuficientei cardiace • anticoagulant oral + protector gastric (IPP) • vasodilatatoare pulmonare (prostacicline sintetice, antagonisti ai receptorilor de endotelina 1, inhibitori ai fosfodiesterazei-5) • Tratamentul poliglobuliei secundare: flebotomii repetate cu inlocuire izovolumica • Chirurgical: depasit

  14. Particularitatea cazului • Pacienta cu boalacardiacacongenitalacianogenacomplexaneoperataajunge la varsta de 30 ani. • Asociereacelor 3 factori de risctrombogeni (poliglobuliasecundara, consumul de contraceptive oralesiprezentaanticoagulantuluilupic) aduce un prognostic grav in plus pacienteinoastre.

  15. Date generale (1) • Reprezinta 3% din totalul malformatiilor cardiace, aparand la 2 nasteri din 10000) • Afecteaza in mod egal ambele sexe. • Asocierea frecventa cu Sindrom Down (20%)

  16. Date generale (2) • Tipuri de canal atrio-ventricular comun: • Partial (incomplet): DSA OP + cleft VMA, ± DSV ± cleftVT • Complet: un singur inel atrioventricular cu 4-6 cuspe sau 2 hemivalvemitro-tricuspidiene

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