Valvulopathies

Souffles innocents

Indications à la réalisation d'une échocardiographie transthoracique:

• Souffle diastolique: toujours
• Souffle systolique:
  1. a systolic murmur grade 3/6 or higher (grade 3, moderately loud murmur; grade 4, loud murmur associated with a palpable thrill; grade 5, very loud murmur but cannot be heard without the stethoscope; and grade 6, can be heard without a stethoscope);
  2. late or holosystolic murmurs;
  3. diastolic or continuous murmurs; or
  4. murmurs with accompanying symptoms.

Valve aortique

Sténose aortique

• In patients with symptoms of aortic stenosis and discrepancies between the physical examination and echocardiographic findings, the severity of stenosis should be established with cardiac catheterization before aortic valve replacement is performed.
• Traitement:
  • Chirurgie de remplacement de la valve aortique
  • TAVI
  • Traitement médicamenteux: diminution de la post-charge. Vasodilators should be used with caution in patients with aortic stenosis and heart failure symptoms.
  • Pas de β-bloquant

Pseudosténose aortique

• Caractéristiques:
  • Low-flow, low gradient: sténose aortique sévère avec surface aortique < 1 cm², gradient moyen transaortique < 30 mmHg (ou < 40 mmHg) et fraction d’éjection < 35 % (ou 40 %)
• Problème: la chirurgie sera inutile et risquée dans les cas de pseudosténose → importance de la différencier d'une sténose aortique sévère vraie par une échocardiographie de stress à la dobutamine avec effet inotrope positif et augmentation de la surface d'ouverture de la valve en cas de pseudosténose.

Insuffisance aortique

Insuffisance aortique aiguë

• Chirurgie d'urgence

Insuffisance aortique chronique

• In cases of chronic aortic regurgitation, surgery with traditional open aortic valve replacement is advised for patients with symptoms (typically, dyspnea or angina), those with LV dysfunction (ejection fraction <50%), or patients undergoing other cardiac surgery.
• In the absence of these findings, surveillance echocardiography every 6 to 12 months is recommended.

Valve mitrale

Sténose mitrale

• CAVE rechercher une fibrillation auriculaire (présente dans 50% des cas si sténose mitrale) car risque thrombo-embolique 20-25% → on parle de fibrillation auriculaire valvulaire, anticoagulation d'office par Anti-vitamine K
• Traitement médicamenteux: Medical therapy for mitral stenosis consists of diuretics or long-acting nitrates, which may help alleviate symptoms such as dyspnea. In addition, β-blockers or nondihydropyridine calcium channel blockers can lower heart rate and improve left ventricular diastolic filling time.

Insuffisance mitrale

Synonyme: régurgitation mitrale

Primaire

• Chronic primary mitral regurgitation relates to processes involving any portion of the mitral annulus. Common causes of primary mitral regurgitation are mitral valve prolapse (also known as myxomatous or degenerative mitral valve disease), radiation therapy, rheumatic disease, and cleft mitral valve.
• Traitement: Mitral valve repair is strongly recommended for chronic severe primary mitral regurgitation
  • in symptomatic patients with left ventricular ejection fraction greater than 30%,
  • asymptomatic patients with left ventricular dysfunction,
  • and patients undergoing another cardiac surgical procedure.

Secondaire

• Chronic secondary mitral regurgitation involves causes other than the annulus, such as ventricular dysfunction.

Traitement

• Mitral valve repair is strongly recommended for chronic severe primary mitral regurgitation in
  • symptomatic patients with left ventricular ejection fraction greater than 30%
  • asymptomatic patients with left ventricular dysfunction
  • and patients undergoing another cardiac surgical procedure.
• Insuffisance mitrale aiguë: ballonnet intra-aortique à contrepulsion

Valve tricuspide

Insuffisance tricuspidienne

• Causes of tricuspid regurgitation include rheumatic disease, radiation, endocarditis, myxomatous degeneration (prolapse), congenital abnormalities (Ebstein anomaly), carcinoid disease, and trauma (for example, chest wall impact or right ventricular biopsy). Placement of internal device leads for pacemakers and cardioverter-defibrillators is also a common cause of tricuspid regurgitation.

Références

Cardiomyopathie hypertrophique et obstruction dynamique intraventriculaire: https://www.revmed.ch/RMS/2002/RMS-2393/22223