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ipertensione polmonare, imaging del ventricolo destro

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ipertensione polmonare, imaging del ventricolo destro

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ipertensione polmonare, imaging del ventricolo destro

  1. 1. Imaging del ventricolo destro nel paziente con ipertensione polmonare Claudia Raineri Divisione di Cardiologia,Fondazione IRCCS Policlinico San Matteo Pavia
  2. 4. Ruolo dell’ecocardiografia nell’Ipertensione arteriosa polmonare <ul><li>Stima delle pressioni polmonari </li></ul><ul><li>Diagnosi differenziale con cardiopatie congenite e malattie del cuore sinistro </li></ul><ul><li>Studio delle a lterazioni morfo-funzionali del cuore dx e sx causate dall’IP </li></ul><ul><li>Prognosi </li></ul>
  3. 5. Ruolo dell’ecocardiografia nell’Ipertensione arteriosa polmonare <ul><ul><li>Stima delle pressioni polmonari </li></ul></ul>
  4. 6. <ul><li>La Vmax del jet della IT dipende dal </li></ul><ul><li>Δ P tra Ventricolo e Atrio Destro </li></ul>Δ P = 4 x V 2 PAPs = (4 x V 2 ) + PAD Stima della Pressione Sistolica Polmonare
  5. 7. <ul><li>Facile, però: </li></ul><ul><li>Stima, non misura (misura di 1 di 2 componenti della pressione: gradiente + stima della pressione atriale destra - 0 a 30 mmHg) </li></ul><ul><li>Non sempre fattibile (70-90 % PAPs e 40-80% PAPd in pz con cardiopatie sx) </li></ul><ul><li>Non sempre accurata ( sotto-stima per allineamento sub-ottimale del Doppler; sovra-stima se lettura erronea delle velocità del getto) </li></ul>Stimare le pressioni in arteria polmonare
  6. 8. Mukerjee D et al. Rheumatology 2004;43:461-466 Relazione tra stima al Doppler e pressione polmonare media cruenta 25 Falsi positivi Falsi negativi
  7. 9. Diagnosi precoce: screening nelle popolazioni a rischio <ul><li>familiari di pz con IAPI </li></ul><ul><li>connettiviti sistemiche </li></ul><ul><li>patologie ematologiche </li></ul><ul><li>infezione HIV </li></ul><ul><li>ipertensione portale </li></ul><ul><li>cardiopatie congenite </li></ul><ul><li>patologie polmonari </li></ul><ul><li>pregressa embolia polmonare </li></ul>
  8. 10. Ruolo dell’ecocardiografia nell’Ipertensione arteriosa polmonare <ul><ul><li>Diagnosi differenziale con cardiopatie congenite e malattie del cuore sinistro </li></ul></ul>
  9. 11. S. di Eisenmenger
  10. 12. <ul><li>Facile, però: </li></ul><ul><li>IP anche in pz con shunt extracardiaci come Botallo (misconosciuti se non cercati, anche con TEE) o DIA tipo OS (anche questi non sempre rilevati) </li></ul><ul><li>IP moderata anche secondaria a disfunzione diastolica del ventricolo sx. soprattutto nei pz anziani (in genere la disfunzione diastolica è acuta) </li></ul>Definizione eziologica (cardiopatia congenite o acquisite)
  11. 13. Ruolo dell’ecocardiografia nell’Ipertensione arteriosa polmonare <ul><ul><li>Studio delle a lterazioni morfo-funzionali del cuore dx e sx causate dall’IP </li></ul></ul>
  12. 14. Alterazioni morfo-funzionali del cuore destro e sinistro
  13. 15. Alterazioni morfo-funzionali del cuore destro e sinistro
  14. 16. Ruolo dell’ecocardiografia nell’Ipertensione arteriosa polmonare <ul><ul><li>Valutazione della Prognosi </li></ul></ul>
  15. 17. Time PVR CO Symptom Threshold Right Heart Dysfunction Progressione dell’ IAP PCP “ In fact, although the pulmonary vascular bed is the primary cause of the disease, right heart failure is the leading cause of death” Torbicki A, Vizza D. 3rd World Symposium on PAH. Venice, June 2003 Presymptomatic/ Compensated Symptomatic/ Decompensating Declining/ Decompensated
  16. 18. Predittori prognostici nell’IAP P(t) = H(t) A H(t) = 0.88-0.14t+0.01t 2 A = e (0.007325x)+(0.0526y)-(0.3275z) (x=PAPm, y=RAP, z=CI) “ Mortality in PPH is largely associated with hemodynamic variables that assess right ventricular function ” NIH registry: Ann Intern Med 1991; 115:343 J Sandoval et al: Circulation 1994; 89:1733
  17. 19. Come valutare la prognosi dei pz con IAP secondo le LG?
  18. 20. Come valutare la prognosi dei pz con IAP usando l’ecocardiografia? Parametri eco correlati alla prognosi: Indice di Tei Riduzione % area ventricolare dx TAPSE Versamento pericardico Indice di eccentricità del v sx Entità rigurgito tricuspidale Dimensioni atrio destro Collassabilità VCI
  19. 21. (valore normale <= 0.3) Tei et al, J Cardiol. 1995 Funzione ventricolare destra: indice di Tei
  20. 22. diastole sistole FAS = 12% Funzione ventricolare destra: riduzione percentuale delle aree (valore normale>=35%)
  21. 23. TAPSE=13mm (valore normale ≥ 17 mm) Funzione ventricolare destra: escursione sistolica dell’anello tricuspidale
  22. 24. Studio prospettico monocentrico 63 PH (47/13/3 PAH/Pneumo/CTEPH) NYHA I-IV ROC analysis TAPSE <18mm per SVI <29ml/m2 (CI < 2,2 l/min) PR Forfia et al, AJRCCM 2006 Stratificazione prognostica con ecocardiografia
  23. 25. Funzione ventricolare destra: indice di eccentricità del ventricolo sinistro
  24. 26. Diastole: e.i. = 2 Sistole: e.i. = 2 (valore normale = 1) Funzione ventricolare destra: indice di eccentricità del ventricolo sinistro
  25. 27. Parametri eco e prognosi: Il versamento pericardico
  26. 28. Stratificazione prognostica con ecocardiografia Raymond RJ. Et al. JACC 2002 Studio prospettico multicentrico randomizzato in aperto 12w. 81 IPAH, NYHA III-IV
  27. 29. Int J Cardiol 2010;140:272–278 59 pz con IAP Classe NYHA III/IV Follow-up mediano di 52 mesi
  28. 30. Ma è solo la funzione del ventricolo destro che conta ai fini della prognosi o conta anche la struttura del ventricolo? Come valutare la prognosi dei pz con IAP usando l’ecocardiografia?
  29. 31. <ul><li><Improved survival may result possibly from preservation of RV function as the RV does not undergo remodelling at birth and remains hypertrophied> </li></ul>ESC Guidelines 2009 Ma conta anche la struttura del ventricolo dx Mc Laughlin et al. Chest 2004
  30. 32. 72 pz con IAP Follow-up mediano 32 mesi
  31. 33. Come valutare la prognosi dei pz con IAP usando l’ecocardiografia? 10 parametri eco correlati alla prognosi: qual è il più utile? Sono tutti indicatori di f v dx (correlati fra loro) e quindi non è possibile scegliere con una analisi statistica multivariata. Anziché cercare il “magic bullet” è più utile un approccio fisiopatologico, multiparametrico, come nello scompenso cardiaco.
  32. 34. Ruolo dell’eco nell’IAP-Conclusioni L’ecocardiografia color Doppler è valida metodica di screening delle popolazione a rischio Ruolo diagnostico complementare Ruolo aggiuntivo nella stratificazione prognostica
  33. 35. Possibilità di ottenere informazioni morfologiche, funzionali e tissutali con elevata risoluzione spaziale, senza dover ricorrere ad assunzioni geometriche Imaging avanzato nell’IAP: RM cardiaca
  34. 36. RM-Valutazione morfofunzionale: VMI
  35. 37. RM-Valutazione morfofunzionale: VMI
  36. 38. <ul><li>Volumi telediastolico, telesistolico , FE, stroke volume e portata cardiaca </li></ul><ul><li>Massa miocardica </li></ul><ul><li>Configurazione del setto interventricolare </li></ul><ul><li>Stiffness arteria polmonare </li></ul>RM-Valutazione morfofunzionale: VMI
  37. 39. Hagger et al, Rheumatology 2009 RM-Valutazione morfofunzionale: VMI
  38. 40. Hagger et al, Rheumatology 2009 RM-Valutazione morfofunzionale: VMI
  39. 41. Gan et al . Chest 2007 Pulsatilità = Max A - Min A /Min A x100 Valutazione morfofunzionale:pulsatilità AP
  40. 42. Valutazione morfofunzionale:pulsatilità AP Gan et al . Chest 2007
  41. 43. <ul><li>Tipicamente alla giunzione fra VS e VD </li></ul><ul><li>Non correlato all’eziologia dell’IP </li></ul><ul><li>Non espressione di lesione ischemica ma fibrosi </li></ul><ul><li>Significato clinico-prognostico non univoco </li></ul>Contrast-Enhanced Imaging
  42. 44. Flussimetria
  43. 45. Nogami, J Magnetic Resonance Imaging, 2009 Correlazione RM-cateterismo cardiaco
  44. 46. <ul><li>Metodica non invasiva in rapido sviluppo che </li></ul><ul><li>consente valutazione multiparametrica sia </li></ul><ul><li>morfologia che funzionale </li></ul><ul><li>Impiego sia nella diagnosi che nel follow up dei </li></ul><ul><li>pazienti con ipertensione polmonare </li></ul><ul><li>Valutazione prognostica </li></ul>RM-Conclusioni

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