Stenosi tricuspidale
Definizione
La stenosi tricuspidale consiste in un restringimento della valvola tricuspide che ostacola il passaggio di sangue dall’atrio destro al ventricolo destro. Come per la maggior parte delle stenosi valvolari, anche in questo caso la causa più frequente è la febbre reumatica, e generalmente si osserva un coinvolgimento concomitante della valvola mitralica, che è responsabile della maggior parte delle manifestazioni cliniche. Va sospettata in quei pazienti che presentano un miglioramento dei sintomi della patologia mitralica, come per esempio la dispnea, che vengono sostituiti da manifestazioni cliniche di insufficienza cardiaca destra. Tale fenomeno può essere dovuto anche alla comparsa di ipertensione polmonare. Altre cause più rare di stenosi tricuspidale sono l’atresia congenita della valvola (sindrome di Nooan e di Alagille), i tumori dell’atrio dell’atrio destro e la sindrome da carcinoide (che provoca più frequentemente insufficienza tricuspidale). In generale è più frequente nel sesso femminile.
Fisiopatologia
L’aumento di pressione in atrio destro provoca congestione venosa. La diagnosi si effettua misurando l’area dell’ orifizio valvolare o il gradiente medio diastolico (>2mmHg).
Sintomi
Sono in genere mascherati da quelli del vizio mitralico associato. Si può sospettare la stenosi tricuspidale nelle circostanze seguenti:
- Vizio mitralico complicato da stasi giugulare importante, con pulsazioni giugulari sistoliche vigorose.
- Congestione polmonare relativamente poco importante.
- Rullio sistolico xifoideo che aumenta con l’inspirazione.
- Sintomi di insufficienza cardiaca destra (turgore giugulare, epatomegalia, ascite, anasarca) e di bassa gittata (debolezza muscolare, astenia).
Esame obiettivo
In presenza di ritmo sinusale si osserva un’ onda A del polso venoso giugulare prominente. Si ausculta un soffio diastolico a livello del focolaio tricuspidale che aumenta con l’ispirazione (segno di Rivero-Carvallo). Un ulteriore reperto auscultatorio è la presenza di uno schiocco di apertura, che è difficilmente distinguibile da quello mitralico.
Esami complementari
ECG
Dilatazione dell’atrio destro sproporzionata rispetto al grado di ipertrofia ventricolare destra.
Radiologia
Cardiomegalia con dilatazione della cavità di destra.
Ecocardiogramma
E’ la tecnica diagnostica di prima scelta (serve per misurare il gradiente e l’area valvolare).
Terapia
La terapia generalmente è medica (riduzione dell’apporto di sale, diuretici), ad eccezione dei casi gravi (gradiente >5 mmHg o o area <1,5 cm²) e di quelli in cui si debba intervenire chirurgicamente sulla valvola mitrale. Se la commisurotomia aperta non è sufficiente, è necessario sostituire la valvola e impiantare una protesi. Generalmente si utilizzano protesi biologiche, a causa della maggiore trombogenicità delle protesi impiantate nelle cavità cardiache. Inoltre trattandosi di camere a minor pressione, le protesi degenero più lentamente.
Ti potrebbero interessare:
- Febbre reumatica acuta (FRA)
- Stenosi mitralica
- Insufficienza mitralica
- Intervento di riparazione o di sostituzione valvolare tricuspide
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