Insufficienza mitralica
Table of Contents
Definizione
L’insufficienza mitralica viene definita come la chiusura inadeguata della valvola mitrale che determina rigurgito nell’atrio sinistro; è la seconda valvulopatia per frequenza, dopo la stenosi aortica. L’insufficienza mitralica può essere organica, quando è dovuta a un’alterazione di una delle strutture dell’apparato valvolare (anulus, lembi valvolari, corde tendinee e muscoli papillari) o funzionale, quando è secondaria a malattie del muscolo cardiaco, che portano a dilatazione e/o ad alterazioni contrattili del ventricolo sinistro che impediscono il completo collabimento delle cuspidi valvolari.
Eziologia
- La causa più frequente di insufficienza mitralica isolata è il prolasso della valvola mitrale. Globalmente, invece, l’eziologia più frequente dell’ insufficienza mitralica è la febbre reumatica (30-50%).
- Il prolasso della valvola mitralica è considerato una delle cause di insufficienza mitralica nei paesi industrializzati.
- Vizio congenito: raro, talvolta associato alla sindrome di Marfan o alla comunicazione interatriale di tipo ostium primum.
- Altre cause sono l’endocardite, ischemia miocardica, che può causare disfunzione dei muscoli papillari, la dilatazione dell’anulus mitralico nelle cardiomiopatie e le malattie reumatiche ecc..
Fisiopatologia
Il ventricolo sinistro espelle il sangue simultaneamente in aorta e in atrio sinistro attraverso la valvola mitralica incontinente; il ventricolo sinistro deve svolgere un lavoro supplementare per compensare la quantità di sangue che fluisce nell’atrio durante la sistole. Il ventricolo sinistro si dilata, la sua contrattilità si riduce, la pressione intratriale sinistra aumenta e di conseguenza aumenta anche la pressione capillare polmonare. Si forma una congestione e una stasi polmonare.
Sintomatologia
Nei pazienti con insufficienza mitralica cronica i sintomi spesso non compaiono sino a quando il ventricolo sinistro non va incontro a deficit contrattile. Pertanto, in molti casi, l’intervallo tra l’instaurarsi della disfunzione valvolare e la comparsa di sintomi è lungo e alcuni pazienti con insufficienza mitralica lieve/moderata restano asintomatici per tutta la vita. Nelle forme croniche, a lenta evoluzione, nelle quali la progressiva dilatazione dell’atrio sinistro riesce a limitare l’aumento della pressione nell’atrio stesso e nel circolo polmonare, possono prestarsi più frequentemente un facile affaticamento e una ridotta capacità di sforzo, in conseguenza della riduzione della portata cardiaca. Viceversa, nei pazienti con insufficienza acuta, o anche quelli in cui vi è un peggioramento piuttosto rapido dell’insufficienza, si può avere più facilmente, un aumento significativo della pressione nell’atrio sinistro e nel circolo polmonare, per cui presentano i sintomi legati alla congestione venosa (dispnea. ortopnea, edema polmonare) e all’ipertensione arteriosa polmonare secondaria. L’insorgenza di una fibrillazione atriale, che è piuttosto frequente nei pazienti con dilatazione dell’atrio sinistro, può aggravare i sintomi, comportando un aumento della pressione nell’atrio e un ulteriore riduzione della portata cardiaca.
Esame obiettivo
Il polso carotideo presenterà un aumento rapido e un volume normale, a eccezione del caso in cui vi sia insufficienza ventricolare.
All’auscultazione cardiaca possono immergere i seguenti reperti:
- riduzione di T1;
- sdoppiamento di T2 per chiusura anticipata della valvola aortica;
- può esserci un T3 in caso di insufficienza mitralica grave con disfunzione ventricolare;
- soffio olosistolico ad alta frequenza con picco massimo nel 4°spazio intercostale con irradiazione ascellare;
- talvolta può essere palpato un fremito (la palpazione del fremito viene descritta classicamente come le “fusa di un gatto”);
- in presenza di flusso mitralico abbondante, può essere presente un soffio diastolico da iperafflusso.
Esami strumentali
ECG
- Dati di ingrandimento atriale sinistro e, frequentemente, fibrillazione atriale. In un terzo dei casi saranno visibili segni di ingrandimento ventricolare sinistro e a volte destro a causa dell’ipertensione polmonare.
Radiologia
- Cardiomegalia (ingrandimento della cavità di sinistra). Segni di insufficienza cardiaca.
Ecocardiografia
- Permette di valutare la presenza di insufficienza mitralica. Valutare la gravità del rigurgito.
- Valutare la severità dell’insufficienza.
- Valutare l’anatomia della valvola e dell’apparato sottovalvolare per cercare di individuare la causa dell’insufficienza.
- Valutare la funzione sistolica del ventricolo sinistro (frazione di eiezione, diametri ventricolari).
- Rilevare la presenza di trombi o altre alterazioni.
Terapia
Controllo periodico della disfunzione e dei diametri ventricolari mediante ecocardiografia.
Trattamento della fibrillazione atriale, se presente.
Il trattamento medico dell’insufficienza cardiaca deve essere intrapreso in attesa dell’intervento chirurgico o nel caso in cui quest’ultimo sia controindicato in quanto troppo rischioso. E’ previsto l’ impiego di vasodilatatori che, con il ridursi del postcarico, facilitano l’uscita del sangue dall’aorta e riducono il rigurgito, apportando benefici clinici.
I farmaci maggiormente utilizzati sono gli ACE-inibitori, caratterizzati da un effetto venodilatatore in grado di ridurre anche il precarico, migliorando quindi la congestione polmonare e la dispnea. Sono inoltre utilizzati diuretici, digitalici, i nitrati ecc..
La terapia anticoagulante è raccomandata per un periodo di 3 mesi in seguito a riparazione della valvola o a tempo indeterminato in caso di fibrillazione atriale concomitante o di impianto di protesi metalliche.
Chirurgica
Nell’insufficienza mitralica grave si deve sempre valutare se sia indicato ricorrere all’intervento chirurgico, il quale consiste nella sostituzione della valvola mitrale con una protesi meccanica o biologica, oppure, quando le lesioni anatomiche lo consentano, nella sua riparazione. La riparazione della valvola (valvuloplastica) dovrebbe essere sempre preferita quando è tecnicamente possibile e sia prevedibile un risultato efficace e durevole; essa è, infatti, associata una minore mortalità operatoria e a una migliore prognosi a distanza, oltre che a una più facile gestione del paziente, grazie alla possibilità di evitare la terapia anticoagulante (rispetto all’uso di protesi meccaniche).
La chirurgia ricostruttiva si avvale oggi di tecniche raffinate, che prevedono l’uso di anelli protesici di varia forma e, se necessario, di corde tendinee artificiali. Secondo le attuali linee guida, l’intervento chirurgico è indicato nei pazienti con insufficienza mitralica grave di origine organica che siano sintomatici e presentino una funzione ventricolare sinistra ancora normale o solo lievemente o moderatamente ridotta (frazione di eiezione >30%). In presenza di disfunzione ventricolare sinistra grave (frazione di eiezione <30%), viceversa, dato l’elevato rischio operatorio, l’intervento andrebbe riservato ai casi refrattari al trattamento farmacologico, e solo quando è possibile seguire una valvuloplastica e il paziente non presenta importanti comorbilità; altrimenti è preferibile il trattamento farmacologico.
Ti potrebbero interessare:
- Fibrillazione atriale
- Stenosi mitralica
- Stenosi aortica
- Sindrome di Marfan
- Insufficienza mitralica a 40 anni: cosa fare?
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