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Cardiopatie funzionali Brunelli


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Cardiopatie funzionali Brunelli

  1. 1. sabato 29 giugno 13
  2. 2. sabato 29 giugno 13
  3. 3. sabato 29 giugno 13
  4. 4. T Sagittal T1-3D VIBE sequences following gadoterate meglumine administration in a normal placenta. ∼ 2 min The signal enhancement of the intervillous space was intense and homogeneous, with rapid kinetics throughout the entire parenchyma, as anticipated in such a low resistance, low pressure and high flow district where the exchange processes need to be optimized. sabato 29 giugno 13
  5. 5. T Sagittal T1-3D VIBE sequences following gadoterate meglumine administration in a IUGR placenta ∼ 4 min. The placenta of patients with fetal IUGR showed many patchy unperfused areas ; therefore, occluded maternal spiral arteries behave like terminal arteries, with no shared circulation between different sectors of the intervillous space. sabato 29 giugno 13
  6. 6. Brain sparing Hind sparing Liver sparing Meccanismi reologici di adattamento alla ipossia sabato 29 giugno 13
  7. 7. Aumento del precarico: massiccia vasodilatazione del dotto venoso con inversione del flusso nel sistema portale Aumento del postcarico: vasocostrizione del dotto arterioso con aumento dello shunt intracardiaco. Implicazioni funzionali per il miocardio (1) sabato 29 giugno 13
  8. 8. Deterioramento della condizione inotropa. Implicazioni funzionali per il miocardio (2) sabato 29 giugno 13
  9. 9. Protons directly compete for Ca" binding at the regulatory sites of TnC, but this competition is influenced by pH-dependent alterations in the interactions of TnC with neighboring proteins, especially TnI. Expression of the ssTnI isoform in developing myocardium has been proposed to provide a significant protective effect on force in fetal/neonatal hearts during ischemia. Indeed, TnI acts as an important pH sensor in an isoform- specific manner. Protezione della condizione inotropa del miocardio fetale sabato 29 giugno 13
  10. 10. Early/atrial ratio (atrioventricular flow) Myocardial performance index Tissue Doppler Imaging Functional assessment of the fetal heart Venous flow assessment sabato 29 giugno 13
  11. 11. Myocardial tissue Doppler (MTD) ultrasonography is a technique that allows measurement of myocardial velocimetry in systole and diastole without the limitations of transvalvar mitral and tricuspid flow analysis by conventional Doppler, which is influenced by a high cardiac rate and by preload and afterload conditions. sabato 29 giugno 13
  12. 12. Alterazioni del flusso nel dotto venoso sabato 29 giugno 13
  13. 13. Proprietà batmotrope; ruolo dell’asfissiaPerdita del controllo autonomico: ritmo idiocardiaco X sabato 29 giugno 13
  14. 14. Testo Alterazioni inotrope e batmotrope; timing del parto nell’asfissia sabato 29 giugno 13
  15. 15. ...while we strongly believe that flow measurement in the DV is an important indicator of fetal condition, in some cases DV pathology is not representative of the fetal condition. Caution is warranted when using single Doppler measurements to trigger delivery... a combination of various parameters constitutes the best approach... ...Clinica... Alterazioni isolate nel flusso del dotto venoso; ruolo nelle condizioni non asfittiche sabato 29 giugno 13
  16. 16. (1) how many fetuses with anti- SSA/ Ro have prolonged PR intervals? (2) is first degree block predictive of more advanced forms of AVB? (3) which is the outcome of first degree block? 98 fetuses definition of first-degree AVB; ≥ 150 msec. Occurrence of first-degree AVB; 3 cases. Occurrence of third degree block; 3 cases; NO ONE with previous abnormal P-R interval. First-degree AVB outcome; 1 case reversed to normal sinus rhythm spontaneously and 2 cases with DEXA. 24 fetuses definition of first-degree AVB; ≥ 95 percentile. Occurrence of first-degree AVB; 8 cases. First-degree AVB outcome; 6 cases spontaneously reversed to sinus rhythm, 1 progressed to complete block and 1 showed recovery from second-degree block after DEXA. AVB grado 1 sabato 29 giugno 13
  17. 17. BAV congenito da autoanticorpi; grado 1vs. 2/3 sabato 29 giugno 13
  18. 18. Which is the response of advanced heart block to DEXA treatment ? 6 cases of second-degree heart block; 3 progressed to grade 3, 2 stabilized at grade 2 and 1 reverted to normal sinus rhythm. 22 cases of complete heart block; no reversal observed. sabato 29 giugno 13
  19. 19. Less intensive surveillance. It remains unproven whether a prolonged PR interval represents a putative “biomarker” of early disease. Fetal conduction disease can progress exceedingly rapidly. First- degree AV block may not be a necessary precursor to third-degree AV. Perhaps the “PR-fect solution” can be identified by a multicenter randomized trial comparing observation alone with treatment following an “abnormal PR. Second-degree AV block should be treated with fluorinated steroids, and acute third-degree AV block may benefit given the possibility of rare, albeit transient, reversibility. Dexa can also benefit cases with complete heart block associated with fetal hydrops. [ sabato 29 giugno 13
  20. 20. Algoritmo procedurale per colestasi gravidica 38 wk 37 wk sabato 29 giugno 13
  21. 21. Il trasferimento netto di acidi biliari al feto non è funzione della concentrazione assoluta ma della permeabilità placentare, in base ad una risposta individuale ad insulti ossidativo/infiammatori Colestasi gravidica; patogenesi sabato 29 giugno 13
  22. 22. Pitfalls of the proposed algorhytm. In utero fetal death from intrahepatic cholestasis of pregnancy is cardiogenic, can be abrupt in nature and cannot be predicted reliably from reactive nonstress tests. sabato 29 giugno 13
  23. 23. sabato 29 giugno 13
  24. 24. a low number of participants Ursodeoxycholic acid or antihistamines might be responsible for the increased fetal PR interval that was seen in ICP in this study. Despite the limitations of this study, we demonstrated a potential difference in the conduction system in fetuses of pregnancies that were complicated by ICP. Further studies of the fetal PR interval are needed to evaluate whether this or other measurements may be of any clinical benefit as an instrument to predict adverse fetal outcome in ICP. sabato 29 giugno 13
  25. 25. Monocorialità: TTTS e sequenza TRAP sabato 29 giugno 13
  26. 26. Progressiva contrazione dello spazio intravascolare sabato 29 giugno 13
  27. 27. Ventricular hypertrophy is present (1 point) if the free walls of the ventricle or ventricular septum appear thickened or if the right ventricle free wall or ventricular septum thickness exceeds 2 SD from the expected mean for gestational age (1 point) Cardiac dilation/enlargement is graded as a normal heart size (0 points) when the cardiothoracic ratio is ≤1/3, as mild (1 point) when the cardiothoracic ratio is >1/3 but <50%, or more than mild (2 points) when cardiothoracic ratio is ≥50%. Systolic function is evaluated by calculation of the percentage of shortening fraction = [ventricular end-diastolic dimension - systolic dimension]/end-diastolic dimension. No dysfunction (0 points) is the percentage of systolic function at ≥30%; mild dysfunction (1 point) is the percentage of systolic function at SF <30% but >20%; more than mild dysfunction (2 points) is the percentage of systolic function at <20%. Tricuspid and mitral valve regurgitation are graded as none (0 points), mild (1 point) when the regurgitant jet area is ≤25% of the atrial area, or more than mild (2 points) when the regurgitant jet area is >25% of the atrial area. Tricuspid and mitral valve Doppler in- flow interrogation; 2-peak signal (0 points) or single peak signal (1 point). Decreased right ventricular compliance; blood flow in the ductus venosus (1 point) or absent/reversed blood flow with atrial contraction (2 points) umbilical venous blood flow pulsations (1 point). The pulmonary artery may be equal to the aorta (1 point) or smaller than the aorta (2 points); for frank right ventricular outflow tract obstruction (3 points). In the donor. diminished (1 point) or absent or reversed diastolic blood flow (2 points) of the umbilical artery. 1 0-5 2 6-10 3 11-15 4 16-20 sabato 29 giugno 13
  28. 28. Preterm delivery was strongly associated with the development of hydramnios and congestive heart failure in the pump twin. If the twin-weight ratio was above 70%, the incidence of preterm delivery was 90% and pump-twin congestive heart failure, 30% compared with 75% and 10%, respectively, when the ratio was less. Predizione del “fetal demise” nella TRAP sequence (1) Rapporto peso gemello acardico Sviluppo di idrope Evidenza di focolai ischemici sabato 29 giugno 13
  29. 29. Predizione del “fetal demise” nella TRAP sequence (2) sabato 29 giugno 13
  30. 30. L'intelletto è sempre ingannato dal cuore. François de La Rochefoucauld sabato 29 giugno 13