Stenosi aortica
La stenosi valvolare aortica può essere congenita ed evidenziarsi già alla nascita o acquisita a seguito di un processo degenerativo che ha comportato la presenza di calcificazioni a livello delle basi delle cuspidi riducendone di elasticità. Questi fenomeni iniziano a manifestarsi sopra i 70 anni in soggetti con valvola anatomicamente normale, mentre intorno ai 50 in soggetti con valvola bicuspide che è presente nel 2% della popolazione, e di per sé non comporta un significativo ostacolo all’ efflusso ventricolare sinistro. Al contrario di quanto avviene nella stenosi aortica reumatica le commessure non vengono intaccate, né tantomeno si fondono. L’eziologia reumatica della stenosi aortica è relativamente rara, ed è più frequente nei casi di un vizio combinato mitro- aortico. La stenosi aortica reumatica risulta dall’adesione e fusione delle commissure e delle cuspidi, con retrazione e irrigidimento dei bordi liberi e presenza su entrambe le superfici delle cuspidi di noduli calcifici che riducono l’orificio.
Sintomi
Il paziente con stenosi aortica è asintomatico per molti anni, nonostante la malattia si aggravi progressivamente. Quando la valvulopatia diviene critica compaiono i sintomi (DAS):
dispnea (segno di scompenso cardiaco)
angina
sincope
Se, da quando insorgono i sintomi la malattia decorre non trattata,
il peggioramento è progressivo e la sopravvivenza media è di
2 anni nei pazienti con scompenso, 3 nei soggetti con sincope
e 5 in quelli con angina.
Nella maggior parte dei casi il primo sintomo è la dispnea da sforzo, seguita eventualmente da ulteriori manifestazioni di insufficienza ventricolare sinistra (ortopnea, dispnea parossistica notturna, edema polmonare). L’angina è presente in circa
2/3 dei casi, ed è simile a quella dei pazienti con coronaropatia, venendo scatenata dallo sforzo e scomparendo con il riposo.
La sincope insorge tipicamente durante sforzo ma può essere anche la conseguenza di aritmie.
L’obiettività caratteristica saliente della stenosi aortica è rappresentata da un polso piccolo e tardo causato dalla ridotta gittata gittata sistolica. L’onda sfigmica appare diminuita di altezza e lenta nel suo manifestarsi in quanto la durata dell’eiezione si protrae e la curva sale lentamente e sembra quasi rallentare a plateau, prima della successiva discesa. La pressione arteriosa
in molti casi si conserva su valori normali.
Diagnostica strumentale
Radiografia del torace: può mostrare un allargamento del margine sinistro dell’ombra cardiaca, dovuta ad ipertrofia del ventricolo sinistro, ma anche un ingrandimento del primo arco di destra (dilatazione dell’aorta ascendente) e una congestione degli ili polmonari (soprattutto nelle fasi avanzate della malattia, in presenza di scompenso cardiaco).
L’elettrocardiogramma rappresenta il test diagnostico non invasivo maggiormente utilizzato per confermare la diagnosi clinica. Il segno elettrocardiografico principale è l’ipertrofia ventricolare sinistra, presente nel 80% circa dei pazienti con stenosi aortica severa.
L’ elettrocardiogramma integrato rappresenta il test diagnostico non invasivo più utile e completo per la valutazione dei pazienti con stenosi aortica. Permette, infatti, di quantificare l’entità del vizio aortico, determinando sia il grado di ipertrofia del ventricolo sinistro e la sua funzione che l’entità del gradiente transvalvolare aortico e l’area valvolare (ecocardiografia Doppler).
Cenni di terapia
I pazienti con stenosi aortica asintomatica non necessitano di trattamento; nei sintomatici la terapia è chirurgica e consiste nella sostituzione della valvola aortica con protesi meccanica e biologica. La sostituzione valvolare aortica con trattamento percutaneo (tramite cateterismo cardiaco) è ancora in fase iniziale, e benché i risultati ottenuti finora siano incoraggianti, necessità di ulteriori conferma e al momento attuale viene riservata soltanto a quei pazienti che pur necessitando della sostituzione valvolare, non possono essere sottoposti ad intervento chirurgico.
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