Ο ΡΟΛΟΣ ΤΩΝ ΚΟΛΠΩΝ ΣΤΗ ΛΕΙΤΟΥΡΓΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΤΩΝ ΚΟΛΠΟΚΟΙΛΙΑΚΩΝ ΒΑΛΒΙΔΩΝ

Transcription

1 Ο ΡΟΛΟΣ ΤΩΝ ΚΟΛΠΩΝ ΣΤΗ ΛΕΙΤΟΥΡΓΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΤΩΝ ΚΟΛΠΟΚΟΙΛΙΑΚΩΝ ΒΑΛΒΙΔΩΝ Ανδρέας Κατσαρός Καρδιολόγος Επιµ. Α Καρδιοχειρ/κών Τµηµάτων Γ.Ν.Α. Ιπποκράτειο

2 ΚΑΜΙΑ ΣΥΓΚΡΟΥΣΗ ΣΥΜΦΕΡΟΝΤΩΝ ΑΝΑΦΟΡΙΚΑ ΜΕ ΤΗΝ ΠΑΡΟΥΣΙΑΣΗ

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5 Functional classification of MR

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7 Ann Thorac Surg 1999; 68:S37-43

8 Mitral annulus Thin, nonconductive, fibrofatty membrane Hyperbolic paraboloid Nonplanar shape reduces the mechanical stress exerted on the valve leaflets Three types of motion: sphincteric contraction translation folding Sphincteric contraction reduces annular area by approximately 25% Am Heart J 2009;158: Circulation 2002; 106:711-7 JASE 2000;13:277-87

9 Circulation 2002; 106:711-7

10 Circulation 1981;64:113-20

11 Mitral annulus A substantial (>50%) presystolic reduction in area has been attributed to left atrial systole It is not seen when atrial activity is absent, for example, during atrial fibrillation or ventricular pacing The mitral annulus also undergoes translational motion along the LV major axis as a consequence of torsion of the base of the LV Am Heart J 2009;158: J Heart Valve Dis 2003;12:31-7 Heart 2008;94:978-83

12 Annular folding Am Heart J 2012;164: J Thorac Cardiovasc Surg 2006;138:1090-9

13 J Card Surg 1997;12:102-9

14 Chordae tendineae The human heart contains >100 chords arising from about 25 major chordal trunks The strut chords, like a stretched rubber band, a r e u n d e r c o n t i n u o u s t e n s i o n, w h i c h i s transmitted to the PMs and fibrous trigones The aortomitral angle is suspended by the tension in the strut chords, which pull on the fibrous trigones Am Heart J 2009;158: Circulation 2003;108: Thorac Cardiovasc Surg 2003;51:190-5

15 Am Heart J 2009;158:887-95

16 Papillary muscles The contraction of the PMs is coordinated with that of the LV as a whole Contraction of helically arranged muscle fibers results in torsional motion around the major axis of the LV The PMs also have a rotational motion around the long axis of the LV Am Heart J 2009;158: Eur J Cardiothorac Surg 2007;32:96-101

17 Am J Physiol 1970;218:

18 Echocardiography 2014;31:

19 Atriogenic Leaflet Tethering The posterior leaflet area available for coaptation may become reduced The posterior leaflet may become more tethered because annulopapillary distance is increased Displacement of the posterior mitral annulus might exert counterclockwise torque, causing tethering of the anterior mitral leaflet Echocardiography 2014;31:

20 Mitral leaflets The mitral valve is metabolically active synthesizing contractile proteins, collagen, elastin, and proteoglycan Valve tissue undergoes remodeling in response to the hemodynamic insults The zone of coaptation measures approximately 1 cm in height Am Heart J 2009;158: Circulation 2008;118(Suppl 1):S243-9

21 Asia Pacific J Thorac Cardiovasc Surg 1994;3:10-6

22 Mitral leaflets During systole, the mitral valve leaflets billow toward the left atrium This curvature reduces leaflet stress acting synergistically with the nonplanarity of the annulus The anterior mitral leaflet undergoes dynamic changes in surface contour throughout the cardiac cycle Am Heart J 2009;158: Circulation 2003;107: J Heart Valve Dis 2008;17:54-61

23 Surgical anatomy of the heart. New York: Cambdridge University Press; p. 55

24 Mitral leaflets Myocytes occupying the basal portion of the mitral leaflets are activated immediately after the left atrium and may play a role in valve closure Like annular contraction, valvular contraction may position the leaflets prior to ventricular systole Valvular contraction may work in tandem with PM contraction to limit the atrial displacement of the leaflets during ventricular systole Am Heart J 2009;158: Cardiovasc Res 1978;12: Am J Physiol 1992;31:H56-62

25 Am J Physiol 1981;241:H

26 The TV complex consists of: three leaflets (anterior, posterior, and septal) the chordae tendinae two discrete papillary muscles the fibrous tricuspid annulus the right atrial and right ventricular myocardium Circulation 1971; 43:333 48

27 Badano L, et al. Eur Heart J 2013

28 Tricuspid annulus Circulation 2006; 114(suppl):I-492 8

29 Tricuspid annulus The tricuspid annulus is very dynamic and can change markedly with loading conditions During the cardiac cycle, there is a 19% reduction in annular circumference ( 30% reduction in annular area) with atrial systole Circulation 1982; 66:665 71

30 Tricuspid annulus Patients with functional TR generally have a more planar annulus, which is dilated primarily in the septallateral direction, resulting in a more circular shape as compared with the elliptical shape in healthy subjects Circulation 2006; 114(suppl):I-492 8

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34 Echocardiography, Vol. 26, No. 8, 2009

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57 Irena Komadinic «Open Heart Surgery»