Insufficienza aortica
Table of Contents
Definizione
L’insufficienza è una malattia della valvola aortica,la quale diviene incontinente per anomalie dei lembi valvolari, delle strutture di supporto (radice aortica ed annulus) o di entrambi. Si verifica, di conseguenza, un flusso retrogrado (rigurgito) di sangue dall’aorta al ventricolo sinistro durante la diastole.
Eziologia
L’insufficienza aortica può essere provocata daanomalie congenite dei lembi (aortica bicuspide, stenosi subaortica con un difetto del setto intraventricolare e prolasso di una cuspide), oppure daalterazioni di origine infiammatoriadegenerativa, come quelle determinate dalla:
• malattia reumatica
• endocardite infettiva
• malattie del connettivo.
I lembi valvolari, inoltre, possono essere danneggiati datraumi chiusidella parete del torace o da lesioni da getto conseguenti a stenosi subaortica dinamica o fissa. Le patologie dell’annulus e della radice aortica comprendono:
dilatazione idiopatica della radice aortica
• ectasia aortica
• sindrome di Marfan
• sindrome di Ehlers-Danlos
• osteogenesi imperfetta
• dissezione aortica
• aortite leutica
e varie malattie del connettivo, tra cui laspondilite anchilosante.
Una valvola aortica bicuspide si accompagna spesso dilatazione della radice aortica e a conseguente insufficienza.Una causa non frequente della malattia è la degenerazione strutturale di una bioprotesi valvolare. L’insufficienza aortica grave, di qualsiasi eziologia, può provocare dilatazione della radice aortica, che esita in progressivo peggioramento del rigurgito valvolare. Le cause più frequenti di insufficienza aorticaacuta, (più rara, in prognosi peggiore) sono:
• l’endocardite infettiva
• la dissezione aortica
• un trauma chiuso del torace.
Patologie della radice aortica
• Ipertensione arteriosa
• Sindrome di Marfan
• Dissezione aortica
• Spondilite anchilosante
• Ectasia aortica
• Lue
Patologie dei lembi valvolari
• Endocardite infettiva
• Congenita(valvola aortica bicuspide, difetto del setto interventricolare,
stenosi aortica localizzata)
• Collagenopatie
• Cardite reumatica
• Rottura traumatica
Sono cause insufficienza aortica.
Sintomi
I sintomi dell’insufficienza aortica dipendono dalla velocità con cui si realizza il danno valvolare, e sono tipici dello scompenso cardiaco sinistro. Se il rigurgito aortico si instaura acutamente, non vi è tempo perché il ventricolo sinistro possa mettere in atto i meccanismi compensatori dell’ipertrofia e della dilatazione, per cui l’ insufficienza ventricolare sinistra si manifesta rapidamente, anche con edema polmonare acuto. I pazienti con insufficienza aortica cronica, invece, sono solitamente asintomatici ed hanno una buona tolleranza allo sforzo per anni, fino a che, con il deficit del ventricolo sinistro, compaiono:
• dispnea da sforzo
• astenia e talora ortopnea
• dispnea parossistica notturna.
Il paziente può anche avvertire palpitazioni a causa della percezione dell’attività cardiaca dovuta all’ ingrandimento del ventricolo. Anche in assenza di malattia coronarica, le aumentate richieste di ossigeno da parte del ventricolo sinistro possono causare angina pectoris, soprattutto nelle ore notturne.
Diagnostica strumentale
L’insufficienza aortica può essere diagnosticata mediante esame stetoscopico che rileva soffi al cuore. Nell’ascolto dei battiti cardiaci si possono avvertire rumori anomali che sono la spia di un difetto valvolare. La diagnosi tempestiva assume un ruolo di primaria importanza per evitare il peggioramento della patologia.
L’elettrocardiogramma (ECG) è un esame fondamentale che può mettere in evidenza un battito del cuore irregolare e il tracciato contiene informazioni utili alla diagnosi.
L’esame diagnostico più importante nella valutazione dell’ insufficienza aortica è l’ecocardiogramma che permette di:
1. valutare l’anatomia dei lembi valvolari e della radice aortica
2. rilevare la presenza e stimare la gravità di un rigurgito(con il color Doppler)
3.caratterizzare la dimensione, la massa e la funzione del ventricolo sinistro.
Il cateterismo cardiaco, l’ortografia e l’angiografia coronarica sono raramente necessari, soprattutto nei casi acuti, e dovrebbero essere eseguiti solo quando la diagnosi non può essere fatta altrimenti o nei pazienti con coronaropatia nota o elevata probabilità di malattia coronarica.
Cenni di terapia
In caso di insufficienza aortica acuta, l’intervento cardiochirurgico immediato è necessario poiché i sovraccarichi improvviso di volume è potenzialmente fatale. In questi casi la correzione chirurgica è urgente poiché la terapia medica usuale fallisce. I vasodilatatori utilizzati per incrementare il flusso anterogrado peggiorano l’ipotensione, l’ischemia e la disfunzione ventricolare sinistra, e i farmaci che incrementano la pressione aumentano le resistenze periferiche e peggiorano il rigurgito.
Laterapia medicanon è in grado di ridurre significativamente il volume di rigurgito nell’insufficienza aortica cronica grave poiché l’area di rigurgito è relativamente fissa e la pressione diastolica è già bassa, e un’ ulteriore riduzione di questa peggiorerebbe la perfusione coronarica. L’obiettivo principale della terapia medica è quindi quello di ridurre l’ipertensione sistolica, al fine di diminuire lo stress parietale e migliorare la funzione del ventricolo sinistro. Per questo possono essere usati i farmaci vasodilatatori qualiACE- inibitori o calcio-antagonisti.Nei pazienti con insufficienza aortica isolata cronica, la sostituzione valvolare (e a volte la plastica valvolare) è indicata solo nei casi gravi, mentre nei soggetti sintomatici ma con insufficienza aortica lieve devono essere escluse le cause di disfunzione ventricolare come coronaropatia, ipertensione e cardiomiopatia.
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