Insufficienza tricuspidale
Definizione
L’insufficienza tricuspidale consiste nel rigurgito sistolico del ventricolo destro in atrio destro.
Eziologia
Si possono distinguere un’ insufficienza tricuspidale funzionale, e un’ insufficienza tricuspidale organica. L’insufficienza funzionale è il tipo più comune ed è secondaria alla dilatazione del ventricolo destro, che comporta dislocazione dei muscoli papillari, abnorme tensione sulle corde tendine e dilatazione dell’anulus tricuspidale. La dilatazione del ventricolo destro è in genere conseguente a un’ ipertensione polmonare, che può essere primitiva, oppure secondaria a valvulopatia mitralica, a cardiopatie congenite o a cuore polmonare cronico.
L’insufficienza organica può essere di natura congenita (anomalia di Ebstein) oppure acquisita. In quest’ultimo caso le eziologie più comuni sono la malattia reumatica, quasi sempre in associazione a valvulopatia mitralica, endocardite infettiva, prolasso valvolare, traumi, radioterapia toracica, ischemia o infarto del ventricolo destro e sindrome da carcinoide. Quest’ultima è caratterizzata dalla produzione, da parte del tumore di sostanze vasoattive, come la serotonina e la bradichinina, che danneggiano l’endocardio del cuore destro e causano deposizione di materiale fibroso sui lembi valvolari.
Sintomatologia
In assenza di ipertensione polmonare, il vizio è ben tollerato. Nel caso più comune di insufficienza secondaria a ipertensione polmonare, la portata cardiaca si riduce e si intensificano i sintomi legati all’ipertensione del circolo venoso sistemico.
Il quadro clinico, quindi, comprende:
- Facile affaticabilità
- Astenia
- Tensione e dolenzia addominale da distensione epatica.
Esame obiettivo
Si possono osservare i dati di congestione destra come epatomegalia, ittero ed edemi declivi. Generalmente è presente distensione delle vene giugulari, con scomparsa della normale onda X del polso venoso e presenza di un’ onda V prominente. Se l’insufficienza è grave, si può palpare una pulsazione epatica durante la sistole definita” polso epatico”, che è dovuta alla trasmissione retrograda del battito ventricolare a causa dell’incompetenza della valvola tricuspide. All’auscultazione compare un terzo tono e un soffio olosistolico a livello del focolaio di auscultazione della valvola tricuspide (4° spazio intercostale sulla linea paresternale sinistra) ed entrambi aumentano di intensità durante l’inspirazione profonda (segno di Rivero- Carvallo).
Diagnosi
Ecocardiogramma
L’ecocardiogramma fornisce la diagnosi definitiva e permette di valutare la severità e la possibile eziologia.
Radiografia del torace
Alla radiografia del torace è evidente cardiomegalia dovuta alla primitiva patologia responsabile della dilatazione del ventricolo destro. A questi segni si associano quelli della dilatazione dell’atrio destro.
Ecocardiogramma con Doppler
Nei casi di insufficienza tricuspidale primitiva l’ecocardiogramma con Doppler consente di identificare l’anomalia responsabile del vizio valvolare e di quantificare l’entità del rigurgito.
Prognosi
L’insufficienza tricuspidale primitiva, se non è di grado marcato, è abitualmente ben tollerata e a lenta evoluzione. Nei casi di insufficienza tricuspidale secondaria, l’evoluzione clinica è prevalentemente determinata dalla patologia primitiva. La sua comparsa, tuttavia, determina un peggioramento delle condizioni cliniche. In questi casi l’entità del rigurgito e il quadro emodinamico complessivo dipendono dall’ intervento terapeutico sull’ ipertensione polmonare.
Terapia
La terapia medica dell’ insufficienza tricuspidale secondaria è caratterizzata dall’uso di alti dosaggi di diuretici, che nelle forme meno avanzate, possono determinare una significativa riduzione dell’ entità del rigurgito. Sono talora utili anche vasoldilatori venosi.
Nel caso di un’ insufficienza tricuspidale di grado moderato- severo associato a valvola mitralica, oltre all’intervento sulla mitrale si realizza un’ anuloplastica tricuspidale. In presenza di patologia organica si preferisce impiantare una protesi.
Articoli correlati:
- Malattia reumatica
- Endocardite infettiva
- Stenosi tricuspidale
- Prolasso della valvola mitralica
- Intervento di riparazione o di sostituzione valvolare tricuspide
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