Capitolul31

PROTEZELE VALVULARE

D. Zdrcnghea,Dana Pop

Prolczclcvl|lvulareutilizatesunrdcdoul lipurirmecanice Suntutilea161ccogrrfir M catgiecograli{B, drrcelemai

ti biologioc.Protczcle mecanice au uvnnll|julcA potfi apli- imnofianre dolcsunllurnimtedeecogralia in modul[)oppler
catcindilcrcntdc mAfireaorificiilorvAlvulrrc$i pe acelaal lmaginea protc/.ck)rvalvularein modulM lii U estedjfe-
liabiLl6lii(durnbilitate
20-25oni).ir schirnbAudezavanrajul ritl ln cazulp()tczclor mecanice 9i protczclor biologice.
in
trrt&mcntului anticoag!lanlcroniccArcsc inrpunepe loatli schimb.in ccogr ti l)opplerdarclclurnizltcsunlsimilorc
durstsvicliibolnav!l0i9ipcacclri | {prrilici mri frecvcolc pentrucclcdord ripurideproterc.
obstruclicidc proteTA.carepoateli rapid \iiincxombilt'arali. I)intrcprolczc.cclc cu bilnapa4iDdc ucumistorieicar-
Eslcdc mcnlioxrtii linLrtconl dc llprul ctrnraioritatea pro- didogiei.Dintrcprotczcle cu disccelcmaiutilizaiesunlcele
lezclormccaniccnu realizeaztr un llur trunsvrlvular central cudiscunicbasculanl (dciip Bjdfk-Shilcysausirnilare). dar
simildrou fluxulbiologicnoflnal. suntdinceinccm{imult folositeprolezclc nrccanicecudoua
in schimbprotezelebiologicc.inscrrtcin mAjoritatea hcmidiscuri (dc tip StJudcsausimilare). Avirndin vedereca
cazunbrpcun inelmeialic. au0vantdiulcli nunecesitnlln ta- ir l |a noosfi luntoclmri muLrlblosilcprorcze lecudiscunic
n cnlanncoagulAntd€ durat!.ctrrcalizcazn unfluxcentralSi bttsculant (Bjdrk-Shilcy) le vomdescriccxclusivpe ac€siea.
orczistcnl!miniml lafluxultransvalvular. in schirno.auoez- Normofuncllaproterolorvalvulrre
rlanlaiuluncifiabiliuli mair€duse, dcgcncrand(calcifiere)in P(,tczelemitrrle mccanicc.Po( li cxaminatein sec-
gcncr.ddupi o perioadlde l0-15ani,\iincccsitandinlocxiren liuneparaslemaliax lung sauseclixne,lc.rmcrcapical.Se
accstora.Dc ascnren€nele nuporii Lrtilizatc in cazulorificiilor cfcclueazn inilial o cv.rhraregenerahin modul B. ulterior
vahuldrcmult dilatatecun sunl indlDitc n)t mai frecvent cfcctuindu-se o cvrlu.rrccantirativn n1nroduI M, te directia
in cazulvalvulopatiilor degencrarivo (saufunclionale). dcschiderii naximc a disculuiprorszei.
Ecocardiografia feprezinhccamaiacuratimetodA nein- In s€ctixncparastcrnala ax lung.nbdul Il. seevideniin-
vazivi de evaluarea functionalilaliiprotczelorvalvulare. zarecouriintcDscalc ineluluiprote(icmcralic(corespund€
Normofunclionalitatea protezelorlallularc poatefi acurirt ccourilorirelului valvularmiiral in cazulval!clor native).
cv.tluatiprin ecografietransloracicl.in cazulmattunctiei <\idenlrLrdL * Ti*JreJ.l scrl r in d|1{,,l:t. r uI ecouInr<n.
d({J,'n,{,'(rrdioFraliJ r'dnqorr. n t (.,r(urii in rrJtonur(d cu deplasare anlcrioari(fi9 I L l)
czurilor. dar in anumitesitualiicstcnccesara recurgerca la lnmodulM scc!nienliaza inelulprotcticnretalicposterior
ccocardiog|afia transesolagiann. caun ecordcnssitualinainieaendocardtrlui perereluiposte-
 Logroha cotuluh1i t i tos..lat dc ld hdza innnii

/|,A,J/.2.P.otc/lin..dio ni(lrli Eco M. ScclLunc x|rcnlii .1

crnrtre se eridenlirzidcpksarca dl0toli.t n discuui ni \rS.
l.l& J././, P olcTinrccrni.:rfillr rlar|.o B. Secliu)el)ar(emo li .x
|!ng irr d]n(oliLr erldenliazinrLicrrcr!flcriodfnr (litculr
ad fi nr clrul prolczclor rncLaliceevaluareacaIlalirn sc
ettctuc!/arnr modul B. iarc!rluarc:r cautitali!.rif mochrlM
r i o r. i i d e plNs r r clnt a c r lo a rl I d rs c u l rii n d i rs l o l a .a s p c cl ul In sccti uncfarr(crns l a { x l un-gscc!i de| l i azi (i ncco ll)
re zu l ta tf iinds inr ilar c uc cl .l u n c i s rc n o rc n ri l ra l c c a l c il l cc . cel ! douaiccouri rl c nl cl ul ulprdcl l c (rdent' c€cu ccou f lc
Seia in cors dcrurc dcthsarc. rn(c orri .rdrsculuiin dirstolir i nel uhi l ni l r!l crl ci Ji c{ l ).i n i l l l crorLrlci for sel rvi d.nl i! zi'
cafe. in c!^l normnuncl(, lirirlii prolczci. dcpirrc$tc l4 rni rcrrc!sl gnn)i dcl or trol cl i cc.snnl l aricLrnri $e!rcx!rl !c i
n u L l I i , l int er c poc iic c o l )o p | l c r s c l L r.l tr n r c o n s i d crarc r i l rnl € ro| rnrl c. In pol i trc rpi c.rl i sc vi zual i zeaziLncLul i
cr i n d i cid. nor nof _unc ti o n rl i l rllc)(' r l c rc r.\c k ,c rrrl c n(l cs- l l rchl i c (l c rscrncnca. pr c
nri i crrcasi grnoi del or
frnctl c ti .
cl ) cri i tr c t e/ ei iilc loc il !1 .. i rrc h i d c rrre c n c i r. d x r o (L rl i i rc ric . (lis. l1 . 5 ).
lll
cu u f0 ri l inc c ogir f lc iI ) o fIL c f.l rn to | 1 fl rl r{ c c s l (,ri rx ti c is' r l | r D r(xi !l M, i f sccl i uncpd.rsl crl l ri lnx i l Lrug.rspcclul
rc(h rs.ci liin( l nui pLr lins ru (tc l o cu l i l i /L i l i . mi i cl l ri i si grnoi del or p(ncl i ec csLci dcnl rcou ccl al Lrr ci
Di rr sc c luner nic r la 4 c a n i c fcn r c c o -8 . s c c l i d c n l i ( rzl \. l \( | ,Irtrl J ri rn' rl J.rJ' n(JIr\ .,:nfLrJ. M t,(| rr, :.E rt '
in ci rLD $i Unf lir r d i fc r (i c n l s rri i rn l c ri o rc d i { $ l o l i -
l r c l. t lic dd dntcdoit$ $i .rspcctdc W pcnlru signroidAposlcriorri.
(. . r.(ul. r ' f r or J I ( . c \:,l .rJ rL rri fd J rrrl .l{ l rf..r .:r. i f rccslcr liind circunrscriscdc (loLn ccouri intcnsc.ccounlc
cco -N .lsc c ! idc ( iar i exc l i rs i vd e p l a s a rc(lr i s c u l u ic. rc l| rc
a ccl rfi a s pc cdc r . , s lc r lo zni ri ttrl l i , l u i n d u -s ci rrc o fs i (l c r rrc
acocuii dcplas0ronrrxilur arterjo rii : l4 nnrr I discului in
crzu l n or nn) lir nc lioi pr otc rc i(l l g .31 .3 )
lihnica Dopplcr olcfi da(ede rnaxirni rcuratefein evr-
lu rrca n o nolir nc lioDa l i l l l i p i ro l e z e l o rme c a u l c eIn i i rh l e.
l,\amin rc.rsoc lccLucazlopL!Ddin secfiulre4 crmerc apical.
liste ulilD(i) cnrcDUuvidcntiazlhsl decetfluxcolorrnozaic
diast(nicb VS. Colomri Lrtilcdalc sum lirrnizated€ D(. cAre
pernriredctcrmirarcagraclicnrultri |l anspfobricii a sxprai'elei
orificiului protctic.l,xisli dcsigLrr!rri.t(ii ale acestor!n1orir'n
fiurciie detipul dcprotc/i ulilizat.ddr,in gcneral,o supralaF
J o n h ci l. r f nr r ( r ir .5 ( n r L r g ra d rJ n l rn r.fro re rr
diasrolicnediu < 8 mm lunt considcralcca scmnc alc nor'
rmlLrnctionalitilii protezeif lI (fis.31.4).
Prot€zele biologicc mitralc (1ip loncs0u Shilcy. I]rn
cock, etc). lndifererr de tipul de protczl ccognJir pcrmitc
elrd€ntier* €courilor nrelului pfotetic hnctalic) $i mitoarca ft&3 r.J.Ptulezli necdici niml. Sec(iurc apicala4 canro!.EcoB.
sign1oldelorproleiice,identici cu aceeaa sigmoidclornairvc. Seevidel1idimitcarca drastolici antcriorli.cudeschidere : 14!rm.
 369

li&J1.4 Protezi mecaniclmihli. Secliuneapicali 4 camere. Fi&JI6. Prore^biologicimilralI Sccliuncparureardld ar lung.

DC. S-auder.aniilr srprafalaoriticiuluii gradientul
Lrdisprorctic Eco-Nl.Sccvidenliaza
deschidcrca
sigrnoideldproictic€ln ir(er;

ftA.Jl.t Protezd
biologiclmilrall.Eco-B.Sccliunc
0picald4 fi&J/.2 PrctezIbnnogic!
mitldi. Sectiunc
apicnld
4 cancrc.nc-
camere. Scovidcnlilzit
clafinelull)rotctic. len inareu qigradicntului
supnlctei mcdiuhansprctctic
- lormat.

ineluluilnctrlic protetic(fig.31.6).Normofirnclia protctici Atai in cazulprctczelormecanicc,oAtSi al prolczclor

nu poatcJi&firmattr ln modulM, din amplitudineamiicnrilor
sigmoidclor prot€tice.Aceasttr cvaluareseefectuesztr optim
prin eco-Doppletr€spectivDC $i DP,valorilenormaleale
supralctciorificiuluivalvui&rli gradientuluitrnnsprotetic
mcdiu(sectiune apicau4 camere)fiind identicccu c€l€ale
protezclormecanice (G:8 mm,suprafata orificiuluiprot€ric
> ).5 cm?)(fi9.31.7).Trcbuicartrrar ctr,deregult,aceste va-
loriiunrinlerioare celorobrinule pentruprok/clc mecanice.
in c,rzulorificiuluiprotclic.$i superioareaccsbra.in cazul
gradicntului transpro€tic mcdiu.
biologice,prinDCosepoateevideni&oinsuffcienlinitratn
protosistolica dc grad mic - 0/1. Evid€ntierea accstciIM
cstcdiffcil! in cazulprotezelor nccanice,datoiiri ccourilor
parazitelirmjzatede disc$i de jnclul metalic(lig.3l.8).De
d.e€ain cazulprot€z€lor mecanicc evaluarea lM ,,fiziobgice"
transprot€tice,sc€fectueaz,optin in secliu1eparaslcmalIax
lungsax,indcosebi, pdn ecogralic trarsesofagianl (1ig.3t.9).
In cazulprolczelorbiologicecvaluarea sepoatccfcctuaatat
in s€ctiuncparasternale ax lung cat Siin secliuncapicald4
cameresautrdnsesofirgiana (fig.3l.I 0).
1',70 Ecosr.rliarcftlului i Msehr.te lu ba.a init,ii

tlkJl /a Protczd nrilrallEcoB Abotdtrsnscsolgian

biologicn
ala.J.l.& Pft,tc/irnecdrici ibiF. S{iiunc apicuE4 umee. txb. Ve Secliunc
tBnsvcrsali. hi'1imilM(sigcala)
Sistoli.Seeaidcnliazio
k)ciLdresisLollcinrAs. DiaEnostic i relM !iecourilc'!da-
dlfcrcnlial pnxezei
cunonnofinclioidlitdrc!
conrpdtibili (v.zicolorphnF?).
ziL alcprctcTcicstel1rlclicimposibild..ibcnrat (vczicol(trnl!n$ ?).

acelarl unci,,proteze mecanicemitrrlc",dar cu deplasarcr

disc lui dcmairnicaamplitudinc (1i9.31.l1).
Accca$idcplasarea disculuiprolclic.de aceastid til
postcrioarl.se poateinregistrA in n dul M pozllionatdlrr
modulB,in scclirme0picalaS canlctc[3].
I)c ccr mni mareinpofianlAc$!cdclcfftinareagftdicn-
rLrluirr n,pr,nrricdin secliunenrnrrstcmalasJn secliun.:
apicrll 5 canrcrc.in odulDC, considcrindu-se nonnalun
gfadicnttrsnspnnctic ma,\imS40 nrmllg(lig.3l.l2).PfinI)l'.
D(: $i cco-Bscpo0tedeteflninasuprlrlhlsoriiiciului protetic.
de imporlartlnlairedusalnstrdecitgndicntultansprotetic.
Suprafala {ccstuiorificiuestedifcriteiD Iuficliede tipul de

&&J1,9,Prolez!mccatricrInilralii.
Eco-ts.
Abo.dtrlnscsotlSian.
DCo.IM dcgradmic- "liziologicli(vczicol(trtlan$
7).

Protozcle,ortice mecsniccrSe€valuc&l din secliune

parasternalnsaupicali 5 camere.
Atitin €co-Bcit $i in cco-
M nu se podtcclcctuadccato €valuarecaliktivd N lirnclicj
protezc,cvidctrliindu-se
0cestor mi$carea sistolicia discului

Clasicevalu,rrca sc clcclueazlin modulM (pozilntd

dtur-o secliureu).
parastcrnali
In sec{irure lr\ lung in nodul M. sevizuNli
zcazaecoulposteriofal mclLrluiaortic$ideplasarca
antcrn'arn l'is.Jl /l ftotez, msdici lonica. sccliunep.mtcmaF !x lufg. Flcl!
sisrolicna disclrluiprordic carcoftrn un aspectsimilarcu M. ScvzualizcaTidopltrsdea etcrioa.a! disculuipro€nc
sisrolicd
 37t

tlh3l./? Prctc7Aaodicdmecrnicd.
ScctilL'rc DC.
supraslcmdh.
Cmdietrttralrsuolelic
naximnonnal
fi&J/./J. Prctczlbidosicddo'licl Scctirncpar0stcnlol!
storg!
ax l!ng. Eco-M.lnsistoldselizualizeazideschiderende
lif box-
prctclicc.
likc' a siSmoidclor
protezAutilizat. ln general 6indconsiderAtAnormallo supra-
fala> 1,5crn:.
Protczclcsorticcbiologicc.j^rrcazulproteTe lor biologice
aorticeil) lnodulU,secliune parastenraliiaxlungsau5 camere
apical.seevidenliaza inehl valvularecogengi migcarea sig-
nroidelorprotetice. similarac! ceaa siglnoidelor nativ€,
in nodul ltl, in sectiune porastemali ax lung,sevizuali-
zcazildcschidcrca & doui sigmoidcprotclicc.dcscbiderea
:rsldr(.l liinJ rinrilRrnrc rrpNr (..boxiilc , cu cc.ri sig-
moidclor nalivc(lig.31.l3). Nu cxisdo evaluorc cnnlihrivd
{ Domalitiltiidcschidcrii sigmoidclor.in gcncraldcschidcrca
nccslorltlinrd rcdusnIall dc ccaa signoidclorn8tivc[4].
Evsluarcsoptrmtrscclcctucvl prin DCls&uDP,prindc-
tcnnrrarcdgrsdicnrului trrnsnrctctic
sau&supmlclciinclului
valvularprotclio. valorilcnonnrlcliindidcnlicccucclcnolatc
in cazulprctczcbrmccanicc(C S 40 mmi A Z l.5cm:).
AtAtin cazulfrotczclor mcosnicccal $i al protczclor
biologicepoatcfi l,rczcru o insulicicnFaorticidc gftrdoil ri& J.l.l.Llfolezl ao(iclinec dcl. Sectiutre D( o.
suprasiem!1..
(iet scudin caleadc ic$irca VS) cvidcnlirtiin DCopozitie hr did$loh sc cvidcnliaza un.iclsourtdc l^o. coNpdtibilr
cu
parast€rnala ax lungsru suprastcmall (fig.ll.l4). nomotunc{iona lil.re.proiezei
(vericolorpl.rt! ?).
Mallunctia prorczclor vrlvulrre
Maltunctiaprotezelor€ste rcprezentattr de obstruclia
proteticl,regurgirarileproteticeSi endocardita bacterianl Clinicobstruclia deFotez6sepoateinstalaacuisaucro-
p€ protezevaNr are. nic.1ncazulinstahii cronicereapar€ treptaisimptonatologia
Obstructiad€ protcz, pentrucares-aefectuatFotezareavali,ular6,inclusivsuflurile
in cazulprotezelor mecanice estesecundara, cvasiexclu- desreno./A \al!,ulrrA,e!erA ln.a,.ulob.rructrer dcure,ein-
si!, trombozeideprotezd,d€ celenai multe ori consecinli a staleazederegxlaedempxlmonaracui,r€zistentla imtament,
unuitatamentanticoagulantinsufici€ntsauinterupt. in cazul ri $occardiogen. Deoarece interventiain cazulobstuctiei
protezelorbiologiceobstrucliade proieznestesecundarn acuteestede maximi urgenlaii €a nu sepoateefbctuain
calcilictuiibioprotezei cu apanliastenozei protehce. lala noasrri decerinlr-un nxn6r mic de cenre, liind de alrt'el
412 Ecogta.fa coftlului Si vdselor de la haza ini"tii

grevatnde o mortalitateridicati, atitudineacea mai indicati

estcdepistarcadft timp a obsh]rdiei de prctozn,dcpistareoptim
efectuatiprin examiniri ecocardiografi ce sena&.
in cazulprotezelormecanicemitrale,principalelesemnede
obstruciie a protezei sunt reprez€ntatede sciderca anplitudinii
diastolicea ni$cini protezeiGub I 4 mm), seventateaobstrucliei
fiinddirectpropo{ionalacu reducercadeschideriiprotez€i[5].
Acestsemnesteoptim inregistr"tprin ecografiaM pozilie
pamsternah stanga sau 4 camere apical (ghidat prin eco-B)
(f g .3 l .l 5 ).
Cel de al doilea semD este rcprezentai de cre$terea gra-
dientului mediuAS-VS diastolic,pesre8 mmHe (fig.31.16).
Avand in vedere cd gradientul tansprotetic diastolic variaze

ftkJl. /6. Pntezlnitrali mecanica.

Seclnme
4 cmereapical.
DC.
cradienlmediu> 8 mmHg- prolczamallinctionall.

sdng).Tot in cazulobstsucliilor cronice,candprotezaeste

"blocattr"in poziliedeschisa, se inregisteaztr ln D(lo. I)l
DC aporiliainsLficienler mrtlnleri grcdulocerteia.
in ca.tul protezelor biologicemiaalestenozarea prctezei
eslcrRre,celmaiadeseacalcifiereaFotezeirczultandin re!€c-
tiasignroidclor Siaparilian sulicienlei nitrale.In cazulin care
ricc&sticomplicalic scproducclolu$i.seva luain considemre
rcduccrca progrcsivio supralclci oriliciuluiproteticfUAdecea
inrcgiskitaprccxtcnrorc (< I .5 cmr)$i crcltcreagradientuluj
lransprotcticdiaslolic> 8 mmllg (iig.3l.l8).Dealtiil,caLcula-
rcasupflrlclcioriliciului proleticesleutill $iln cazuLprot€zelor
mccanicc.liind valsbililacccuiivnloarclimilA de I.5 cmr.
l.i&31..1tPrctcz[mitmliimcca p0r0slc
cI sccliunc ]iIaxlung in
s6ngueco-l\.4. prolclci< |4 mm.in
Dcschidcrca eco.11,
curc.
evidentiazi
cauznobstnrctici- 'lr€unlI
(slgcata).
tfo!)bpcpforczll

penrnr diveriele r,p0ride proreTeuflli7ate.

JeconJrderA;r un
sernomai acuratal obstructiei de protezAcre$terea cu peste
50%a gradientului faF de gradienful
dlastolictransprotetic
transproleiic inregisirat preexternare,
Deoarece trombozade protezlestecauzaceamai fiec-
venttra obsrrucliei protetice.
teorericevidenfierea tronbilor
cslc dc maxinll utiliralc.Din plcac aceasnes(cdilicild.
in sccljunctmnsloracicl,De acecain loalecazurilein carc
sc suspjcioncnzA obstrucli!dc prolczaprin llolnbori sc va
rcclrrgcla ccograliatlrrnsc$l-agianA, carcpemric cvidcolic
r(,,J(L Jrl ,, r.'Thil,r ,i mirri:i r +lor.r.c\ idcr'!\.r((Jr\
confimuobstruclia dc protczdricauzaaccslcia(lig.31.17).
in erzulrh,r-url ciIn,s\.i\c rJnri(rr ,un in t,.runt*.i
scnnele secundare derivatcdininclrcarcahcmodnramici de Fti(.J/./Z lrote2, rilnli necdic6. Eco B.Abod lranscsoti!8ian.
volum.in amonre deprotezi(creitcrca dimcnsiunihratriului ScqnlncmnsvcNdle.Sccvidorliazl trcnrbls nivelulprnerci (sdsqnd).
 373
in cazxlprotezelor in pozi{ieaorticncvaharcaatnplitu-
dinii miwdrii protezeiestemai pulin uliln in diagnostic. De 'orificiul < I cml
utilitatema{imd esteevaluarea gradienluluifansprotetic . DVAo> 21 mm
sistoliccare,in cazulin cared.?ric$lc40 nm, seconsideri . gradicnlnaxim > 30,40nxnHg
un indicatoral obst clieideprolcza(Jig.3I.I9). Esteurili ii . scldcreaarieivalwlarecu 30%1:16dc ciami'
in acestcazcre$ter€a cupcstc50%agradientuluitmnsprotetic nareaprecedenla
sistolicfaF de gradicnrul transproteticpreextemare [6]. . protez€mitale
Evidentierea lronbilor la nivelulprotezei esteextremde . pI{T > 200ns
dificilain €co-B,din abordtranstoracic, fiindmaiu|or efec- .v>l.5mA
tuatn din abord transcsofagian.Diagnosticulrimane totuti . OM < 1.5cln'
dificil, deimportanFmaximi rdmanandcrertereasradientului . gtadientm€diu> 8-I 0 mmHg
transprotctic(> 40 mmHg). . protez€rricuspidc
Sumarizand, seconsidericAexistAo obstrucliea protc- .v>1.5m/s
zclormecanice in urmatoarele situalii: Rcgurglttrrlleintra 9i prraprotetice
Regurgitlrile intraprotcticc sunt mai fiecvenr notar€in
cazulprotcTcl,\r brologice.daloriti calcificariifi reraclicl
sigmoidclor protetice. in schimb,regurgit&ilcparaprotctice
{e inr6lnesccu lrec!enFsim'larain (azulI'r,\reTelor mecanice
saubiologicc,liind scoundarc ffe unordeficiente de tebnic!
chirurgicalil, jcsuturilorperiorificiale de proasticalitatcsau
cndocarditei bacteriene (abces!lineluluivalvulrr).
Regurgiterile intra$i par6prolcli€c determinl,din punct
de\rederecliDic,apariliaunornoi sufluride tip insuficicnF
valvularil,a ctrrorintcnsitat€ estedirectproporlionaltr cu sc-
vcrihtcaregurgitfuii. De asemenea, rcap&rsauscagftrveaztr
scmneled€ insuficienld cardiaci,iar crpachatea de eforta
bolnavuluiscadcprogrcsiv[7,8].
Regurgitsrc$ prototic! mitrrll. IDdiltrcnl dc tipul
.proteTei.in eco-Mti B Duavcmscmncdirccteale acestei
re8urgrriri. Sc fur iDrrgirlraicrnncrndrrecte. respecl\
i.i&JlI8. Prcrcrl nritrali biologioA. cle$lereA dimcnsiunilor VS (ii a contmctilita i acestuia) fi
Sccliunclpicnh 4 c&mcre.
DC Aspccrdc tip slcnotjc0lff{x lui transproletic. crc$lcrcu dimensiunilor AS. dar acestea nu sunt spccificc.
Semnelespecificesuntolcrilc dc ccografirDopplet indi
ferentde modululilizat.carccvidcnliaza prezenla 9i gradul
insuficicntci mitrale(fig.31.20). in plus,ecograii!DClo
IJnnrle e!rdenlierersed,uluiinlraliruLli( str|rJ'uritR,r.:lrr
al insuficienlei milralc.D&c6rcgurgitirileparaprotetice sunr
inlotdeaunn p!k)logicc.in sohimbregursitlrileiniraprorericc
lrebuicdilcrcnliare der€gurgitarile liziologice.Rcgurgirarilc
nrtraprotetjce seconsideripalologiccaluDciclinddcpalcsc
l0% dinvaloareadcbituhridiast)lictransprotetic [7].
R€gurgitlrlle proteticerorticc. I'or fi. de asemenea.
intrirprotelicc sauparapfotctice. Ca $i in cazLrlprorezelor
Inrrrale<.o V r B ru ,'[.r; Jec.,r .enr'errdir(r<.re-p<(I|\
incdrcarea dc voluma VS (crcitercaVTDVS cu hipercon-
traclililatc).EcograliaDopplerpernrireo evaluar€ acurataa
regurgilarii.accasla li inddepista6in toareceletreimodxride
lii'i.3t./9. Prolcz!aortici mccanrcd.
Scciiuresupra(emrl' D(. erannldrc DC.l)P.l)Co(fig.]l.ll). Dalopemitein plxs
G[dicrt traBproletic>40 mnHg. evaluarca scdiuluircgurgitirii,inrrasauparaprotetici.Este
174 E.ogtuJia co ului ti wseb de ld ba,a ininii

ri&Jl2t Proteziaonican.canici
Scqturcapicala5 D(b.
canrcrc.
IAosr||(vezieoldn.nta7).
Rcgu,lit!cinllaprotolicnpalolosic!-

de la implantareaprotez€ivalvulare,gennenuldominrnt
fiind streplococul.
Degi evolutiaestemai gravalin pfirnul caz ca cslc dc
regulilnefavorabiltr fi in ceade-adouasitualieavandin vc-
dercpeflelrorea dilicild 0 antibioticuluila nivehl structurii
protezclor valvulafe,
A!6ndio vcdcrcimponanFnrajortra uneiterapiiantiin-
lcclio6scrRpidiosliluitc.ccocardiogmfi a. inclusivtranseso"
Fi&-ll.2A PRxc/Abi(togici nritrdlil.Scctiuncdpicull 4 cam$c. lagisnescifipunc la loli purldloriideprotezevalvul0recare
(vczicolofplanta7).
DCo.Se0lidenliazloIM gr.ll intrapfotcticil prczinldun siodronrlbbrilcu durattrmailnarede 7 zile.
Diagnosticu I cndocardi|cibncrcricoepeproteze valvolarc
cslc dilicil, dc inlportnnll c.rpitnhiiind si$prornatologia
imporl0nttr evaluarea severitaiiregurgrtarii.o fegurgitare
0/l cliricl \ii iDtcrprctarca d0lcl() coocrrdiogrl|licc.
corclolcu
intraprotetica liil considerata nornald,pecAndvaloricare
clcpil$cscaccslgladsunlconsidcrntepalologice. Reglrgiurile Scmnulnrircifal.caructcristic. I cndocarditcibactcricnc.
IarJIrolcuce rJr)r ir)lolderur)c parologice. rcspcctiv
cvidcnlicrca vcgctaliilorbaclcricnc cstcdilicili sau
in modpractic.scconsiderd cltexis6regurgitarivalvulare imposibillin coogftrlictmnstorrcion, cu cxccpliavcgctnliilor
scmnr vc.cdndariajctuluiregurgilanl
licaLi depltette25%din de maridinr€nsiuni. in o8rcdiagno$licul clinic sc irllpuDc\ii
ariaoriliciuluivalvular.ir cazulproozelormitale nonnalc in absenlaecocrrdiograf ei (fig.3L 22). in schirnb.ccogr&lilt
suprafala jctuluinu rrcbuicslldcpiicasci2cnrr,ial lungimca trans€sofagianapermitevizualiznrervegctaliilorpc valvl
satrcbuicsi iic < 2.5 cm. Pcntruprotcrclcaorticcnon1lalc inclusivmecanica, vizualizandu-se vegetuliilc dc la o rnlrnnc
suprafalaj€tului cstc< I c'n'].iar lunsimcasa< 1.5cm. de l-3 mm.Totugiii in acestcazdiagnosticul difercnlialcu
Endocnrditabrcteriani pe protezev!lvuhre tronbozade protezapoatefi dificil u0l.
Bxistldouitipuri deendocafdilibactcriani. Primulcste Evidenlierea
altorsemnealeendocarditei bactenen€ sau
reprezentat de endocardita bacterian,prccocccarc apare a complicafiilorrcesteiaesiesimihre cu ceaexpusala en-
imediarpostoperaror sauin primeledounlunidupiimplatarea docarditnbacreriand in general.O menliunespecialipentru
protezelor valvulare.in acesttip. cel mai adesea €stevorba rcgurgilnrilcparaprcletice(indilerenrde tipul d€ protezi
de o inlbctie in legftula cu inten enliachirursicali. germenul mccanicdsaubiologica)carcsunrliecventein €ndocardita
dominantfiind reprezentat destafilococ. Cel de-aldoileatip hrcr(-irna
F fr.,rrla{abcc'.rl Inchl,Ir.rlltrlrr))rsupereJ,/d
esteacelal endocarditei bacteriene tardive,dupedoueluni saucon{innl.in contcxlclinic.cndocardinbacierianill0l.
 3',75
:l llaumgannerH. Khan S. DcRobcrtisM. (r/er L. \4ruFr c. Ellccr
oi prosltrelicrofti. ralvcdcsien on $e Dotpler crdrctcrgrdicnrcol
relalion ar in vitfo slldtol nomrl Sr.Jude.\4cdtronic-HalL.Stari r,d
w a r d sa D dH a n c o c kv r l v e s .J A m C o l l a a . d i . l g 92 :1 9 :l :43 2 .
4 Balmgarttur E. Kbln S, DcRobcnisM. (zer L. M.uEr c. Di$
cepdcresbclw.cnDofflcr a.dcalhelergradicntsrn.o|1rcfrosthctrc
valvcs n rifto a hNniiestationof localozcdCradi.nlsa pessure
rccotery.Circulation1990;821146t-?5
5.B1l.r JN, Lcchn ME. Salazar(i, ,/oglbi \\A. Do ccloc.rdi
ogfupbicasscssmcnt {nh the continuil}'equalbn of St. 'lcrhdc Mcdl
cal nrcclranicaprostheses in (le mirml valvc Fsition An.l Cardiol
1 9 9 5 : 7 6 : ? 8973 .
6.librro( P. Ilonos CN. I)urand l,C. Duuesbil JC. Substrturionof
leftvcnlricnlaro!1flotr 1nc1dirh€ter * ith trcsthcsissizcrsinadesurte
for .a cllarion of l]t rortir pRrsthcncv.lvc aEa b)- the conliruity
equxuonJAh Soclchocardlogr l995ilj:5lL 7.
?.Fhchskamff |4. () Shealn Grilln Bl Cucncm L, \\'cymanAl,.
F,?,J.|.?ZProlezi blologicl tr1ilhlJ.llco-8. Sccliuleapicali 4 ThonrasJl) Pnrlen$ol nomtrl transvllvularrceurgital ion h nechsi
camerc. c n ! a ! e p r o l h e s cJsA
. n r C o l l C a r do l l 9 9 l : 1 8 : 1 4 9 3l i .
Scevldcnliazio vcgctati.bacteriani(sdgeal.)ti dnfonrb
pePrcteza (saSedra
dubla). li.Drnlel LB, Cr8F LE. Wclscl ltl). Rrkowski ll CohFrison of
(hDsthor.clc and lensesophngerltr$cssnlcntof froslhdic vrlve
dystunclion,Ecoodrdiography | 990i7r8ll-9j.
Bibliogrrfie 9.Ohros L, S har C. Bdlbcts€s .r. Quinores MA, Zoghbl $ .
Uscluln$s of tmnsthoEciccchoca.diosnrphy in d.rcctinSsi8nlficaflr
LRchn$ S , MeltzerItS. Nonnalvalu$ of pfosthctic valvcl)op- ffosthcticthittul reguryitation,
AD J Cardiol I 999183: I 99-2(15,
p er eohocddiognrplio l,uranel.s:Arclicsr.rAN Soctrchocurdiogr 10.Ricdrdor, RondsosMD, PonisM, Stooimao,r,Samimroc.Ale
1988i1: 20 1 -1 0 . !ll ecbooudiogruph io $ndirgs cquallynrudicli!efo! didgnoskin tfo$
2.Ch6n'bcm JB.MhhLprcssurc halfrinq is it a validnrcusurcofori rhetiocndocadirhl Joumrl o I rheAmtrican SocictyofEcho.srdiog-
f c c ar $indi fi o l h c { { rl !s l J Il c a n Va l v cD199312
k 571-1. raphy(E(:Hl)) 2004i6r664{69