ade id86 emergenze urgenze in cardiochirurgia l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Ade ID86 Emergenze-Urgenze in Cardiochirurgia PowerPoint Presentation
Download Presentation
Ade ID86 Emergenze-Urgenze in Cardiochirurgia

Loading in 2 Seconds...

play fullscreen
1 / 41

Ade ID86 Emergenze-Urgenze in Cardiochirurgia - PowerPoint PPT Presentation


  • 187 Views
  • Uploaded on

Ade ID86 Emergenze-Urgenze in Cardiochirurgia. LA DISSEZIONE AORTICA. Dissezione Aortica. red blood clot. true lumen. false lumen. Scissione longitudinale della media aortica da parte di una colonna di sangue

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Ade ID86 Emergenze-Urgenze in Cardiochirurgia' - lancelot


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide2

Dissezione Aortica

red blood clot

true lumen

false lumen

slide3
Scissione longitudinale della media aortica da parte di una colonna di sangue
  • La scissione della media occupa circa metà della circonferenza dell’aorta e può estendersi per tutta la lunghezza del vaso
  • Lo scollamento creato dal sangue crea un secondo lume o falso lume
slide4

Dissecting aortic aneurysm (aortic dissection). This gross picture highlights a 6cm wide aortic intimal and partial medial tear just above the aortic valve. Most dissections start with a intial tear in the first 10cm of the aorta. Through this tear blood enters, and dissects down the laminar plain of the media. It often will re-enter the vessel lumen in the abdominal aorta or even lower (illiac or femoral arteries).

slide5

Dissecting aortic aneurysm. This is a segment of the abdominal aorta showing the two seperated walls of the dissecting aneurysm (the blood has been removed). The media is seperated easily, like the pages of a book.

Inner 1/3 of media

Outer 1/3 of media with adventitia

slide6

Epidemiologia

  • Incidenza: 1caso/80.000abitanti
  • 350 nuovi casi/anno
  • Età: 40-70 anni
  • M/F: 3/1
classificazione
CLASSIFICAZIONE

Classificazione di De Bakey

  • Tipo I: dissecazione dal tratto ascendente al discendente
  • Tipo II: dissecazione limitata all’arco a al tratto ascendente, senza coinvolgimento del tratto discendente

Tipo III: dissecazione della sola aorta discendente

classificazione8
CLASSIFICAZIONE

Classificazione di Stanford

Tipo A: interessamento aorta ascendente

Tipo B:interessamento arco aortico e/o aorta discendente, non l’ascendente

fattori predisponenti
Fattori predisponenti
  • Ipertensione (75-90% dei casi)
  • S. di Marfan e Collagenopatie
  • Malformazioni aortiche congenite
  • Valvulopatie aortiche acquisite
  • Gravidanza (rara)
  • Forme iatrogene (cateterismi)
  • Abuso di Cocaina
quadri clinici e sintomatologia
Quadri clinici e sintomatologia
  • Lacerazione e sede della lacerazione
  • Progressione dello scollamento con coinvolgimento aa. collaterali
  • Sindrome da compressione
  • Sindrome da rottura
slide11

Sintomi

  • DOLORE (Migrante)
  • 50% STENOCARDICO 30% ADDOMINALE
  • 10% DORSALE 6% LOMBARE
slide12

The pain of dissection is usually sudden, worst at onset, severe, and not previously experienced. Adjectives such as “ripping” and “tearing” often are used by the patient

slide13

SINTOMI LEGATI ALLA PROGRESSIONE

  • Right carotid compression from dissected blood
  • Blood dissected upward from aortic tear
    • Can dissect upward toward carotids or downward toward coronaries
    • Therefore, symptoms may reflect those of a stroke or heart attack
slide14

SINTOMI LEGATI ALLA PROGRESSIONE

  • SINDROMI ISCHEMICHE DELL’ARCO
  • -disturbo della coscienza
  • -lipotimia
  • -mono- emiparesi
  • -plegie
  • -scomparsa polsi periferici arti sup.
  • -asimmetrie di pressione dx-sx
  • OCCLUSIONE AA.SPINALI
  • -parestesie
  • -paraplegie
  • -paraparesi.
  • OCCLUSIONE AA.RENALI
  • -anuria
  • -ematuria
  • -infarto renale
  • -ipertensione nefrovascolare
  • -dolore (colica renale)
  • OCCLUSIONE AA. MESENTERICHE
  • -dolori addominali
  • -infarto intestinale
  • OCCLUSIONE AA. ILIACHE
  • -simula ischemia acuta dell’arto
  • -sciatalgia
sindrome da compressione
SINDROME DA COMPRESSIONE
  • S. Mediastinica per compressione n. laringeo ricorrente
  • S. di Horner per compressione del ganglio stellato
  • S. da compressione esofagea con disfagia
sindrome da rottura

Blood dissected proximally through the media

  • Hemopericardium resulted
  • Cardiac tamponade may be present due to the extreme hemorrhage
SINDROME DA ROTTURA
  • Pericardio
  • Cavità Pleurica
  • Addome
slide18

PROGNOSI

  • Acute Type A dissection is a surgical disease
  • Previous natural history studios show 80-90% one month mortality
  • Two recent series have indicated a 60% one month mortality with non-operative medical therapy
  • Senza trattamento, Ao dissecazione ha un’alta mortalità
  • Il 35% dei pz non curati muore entro le prime 24 ore, il 50% entro 48 ore, il 70% dopo una settimana e l’80% entro 2 settimane.
  • Il tipo B ha prognosi migliore

STORIA NATURALE DELLA DISSEZIONE

SOPRAVVIVENZA TIPO B

SOPRAVVIVENZA TIPO A

iter diagnostico iniziale nel pz con sospetta dissezione aortica
Iter diagnostico iniziale nel pz con sospetta dissezione aortica
  • Esami ematochimici(CPK,CK-MB, T(I)troponina, conta bianchi, D-dimero, emocromo, LDH…)
  • ECG
  • RX TORACE
  • ECO
slide21

ESAMI DIAGNOSTICI

Laboratory data(1)

1. Decreases in the hemoglobin and hematocrit are ominous findings suggesting the dissection either is leaking or has ruptured.

2. BUN and creatinine are elevated if the dissection involves the renal arteries.

3. Hematuria, oliguria, and even anuria (<50 mL/d) may occur if the dissection involves the renal arteries.

4. CKMB and Troponin T may be elevated in acute thoracic aorta dissection

slide22

ESAMI DIAGNOSTICI

Laboratory data(2)

1. In acute thoracic dissection, ECG can mimic the changes seen in acute cardiac ischemia. In the presence of chest pain, these signs can make distinguishing dissection from AMI very difficult. Keep this in mind when administering thrombolytics to patients with chest pain.

STT depression and T wave inversion(red arrow )

diagnostica per immagini
1. Chest X-ray is used as routine screening

2. Contrast-enhanced CT can image arch and descending aorta

3. MRI if available is usually best for imaging ascending aorta

4. Transesophageal ultrasound, if available, especially for root and ascending aorta

5. Angiography is more invasive and has been replaced by many other imaging such CT, MTI

Aortography sens-88% spec-94%

CT sens-83% spec-100% ( noninvasive, need contrast, 3D capabilities)

MRI sens-98% spec-98% (noninvasive, no contrast )

ECHO -TTE sens 59-85% spec-63-96%

ECHO -TEE sens 98% spec 98% ( important disadvantage of TEE is its limited ability to visualize the distal ascending Ao and proximal arch because of interposition of the air filled trachea and main stem bronchus.)

Diagnostica per immagini

Selection of imaging diagnosis

slide24

left pleural effusion

mediastinum widening

Diagnostica per immagini(1)

Chest X-ray

1. Mediastinum widening

2. Displacement of intima calcification

3. Displacement of endotrachea tube and NG tube

4. Left pleural effusion (signs of dissecting ruptire)

slide25

Diagnostica per Immagini (2)

CT scan

1. Intimal flap

2. Displacement of intimal calcification

3. Differential contrast enhancement of true v.s. false lumen

T

Intimal flap

F

slide26

Partition of a three-dimensional contrast-enhanced MRA shows intimal flap (arrows ) in the distal aortic arch and descending aorta.

Diagnostica per Immagini(3)

MRI

1. Intimal flap

2. Slow flow and clot in false lumen

slide27

Diagnostica per Immagini(4)

Transesophgeal echocaediogram

1. Freely movable flap within the lumen of the vessel

2. Differential Doppler detection of true v.s. false lumen

F

T

Freely movable flap within the aorta

slide28

A dissection flap can be seen spanning the aneurysmal ascending aorta.  A defect is noted in the central part of the flap consistent with an entry point from the true into the false lumen.

Colour flow Doppler demonstrates the communication between true and false lumens.

slide29

On 2-D imaging a dissection flap (arrows) is seen within the descending thoracic aorta.

A PW Doppler cursor has been placed in each of  the two lumens shown above. Flow is greater in the true lumen (left) than in the false lumen (right).

Colour flow Doppler confirms the smaller, more posterior lumen, as the true lumen.

slide31

F

Diagnostica per Immagini (5)

Angiography

1. Intimal flap

2. True and false lumen (may be failure if the false channel is thrombosed)

3. Aortic regurgitation

4. Coronary artery

T

Oblique arteriogram of the thoracic aorta demonstrates the double-barrel aorta sign of aortic dissection. Both the true and false lumina are opacified

slide32

PROGNOSI

STORIA NATURALE DELLA DISSEZIONE

Senza trattamento, la dissecazione ha un’alta mortalità:

  • prime 24 ore35%
  • entro 48 ore50%
  • dopo una settimana 70%
  • entro 2 settimane80%.

Il tipo B ha prognosi migliore

slide33

DIAGNOSI E TRATTAMENTO DELLA DISSEZIONE AORTICA

STABILITÀ EMODINAMICA

INSTABILITÀ EMODINAMICA

Sala operatoria

Diagnosi sospetta

Anestesia generale

+ monitoraggio

(TEE)

Diagnosi certa

Terapia Intensiva

Negativo

Positivo

Conferma diagnosi

(TEE)

Diagnosi

sospetta

Diagnostica

inadeguata

Intervento chirurgico

TAC

Pos

Neg

RMN

terapia 1
TERAPIA (1)
  • Pz in ACR con PEA:

RCP

Considerare

PERICARDIOCENTESI

slide35

TERAPIA (2)

Dissezione aortica tipo A

  • Terapia Chirurgica URGENTE
    • Any dissection involving the ascending aorta
    • Symptomatic or complicated descending aortic dissections
slide36

TERAPIA (3)

Dissezione aortica tipo B

  • Terapia Medica
    • Per ridurra P.A. e stress sulla parete arteriosa
    • B bloccanti
    • Vasodilatatori
    • Per il dolore morfina, NO FANS
  • Terapia Chirurgica
    • Symptomatic or complicated descending aortic dissections
slide38

TYPE A

AORTIC

DISSECTION

tear location

true lumen

false lumen

The ruler has been inserted into the tear in the intima that has given rise to the dissection of this vessel. This is a view of the intimal surface of the aorta

TYPE A AORTIC DISSECTION

clots in false lumen and aortic arch reentry

TYPE A AORTIC DISSECTION

clots in false lumen

slide39

A Cabrol interostial coronary graft or an ultra short (1.5-cm) graft-to-left-main extension occasionally is employed when low-lying ostia cannot be mobilized.