Posso eseguire l’esame RM se portatore di protesi valvolare cardiaca?

È possibile eseguire un esame di Risonanza Magnetica in un portatore di protesi valvolare cardiaca?

La Risonanza Magnetica (RM) è un importante metodo diagnostico per immagine, non invasivo (non comporta cioè la penetrazione dei tessuti con strumenti), che trova applicazione in diversi ambiti cardiologici. Per molti pazienti, e quindi anche per i portatori di protesi valvolari, si pone la questione se in presenza degli impianti (corpi estranei di metallo) sia possibile eseguire l’esame RM.

Per corpi estranei di metallo s’intendono sia schegge metalliche penetrate accidentalmente nel corpo (p.es. durante la guerra) oppure parti metalliche inserite con un intervento chirurgico (pace maker, arti artificiali, protesi valvolari). Il rischio di un esame RM è dato in parte dagli effetti del campo magnetico statico e in parte dagli effetti dei campi magnetici che cambiano rapidamente e dalle onde ad alta frequenza.
Il rischio del campo magnetico statico è dovuto al fatto che gli impianti possono spostarsi ed eventualmente danneggiare strutture nervose o vasi ematici.
In questo caso è importante la composizione delle leghe degli impianti. Determinante comunque è la conduttività del metallo.

Le parti metalliche nel tessuto (p.es. un pace maker) possono inoltre fungere da antenna supplementare ed accoppiarsi con la bobina d’alta frequenza del tomografo RM.
Nel corpo estraneo, cioè nell’impianto, si formano turbolenze che potrebbero sviluppare calore. È quindi detrminante la conduttività del metallo. Il calore sprigionato si trasmette al tessuto circostante, e nel peggiore dei casi, il tessuto intorno all’area dell’impianto potrebbe subire bruciature.

Insicurezza di medici e pazienti

I rischi teorici sopra descritti sono spesso motivo d’insicurezza sia per i medici che per i pazienti portatori d’impianto, tanto che frequentemente si rinuncia a priori a questo metodo d’indagine diagnostica.

Nessuna influenza negativa sulle valvole meccaniche

Ampi studi hanno invece dimostrato che non si devono temere effetti negativi dovuti al riscaldamento della protesi valvolare o dalle forze magnetiche.
Diverse pubblicazioni scientifiche sull’effetto del campo magnetico e delle onde radio ad alta frequenza su diversi tipi di protesi valvolari (vedi tabella) concludono che le valvole meccaniche sono assolutamente sicure e non problematiche per i pazienti che si sottopongono all’esame RM. La stessa cosa vale  per le parti metalliche e fili metallici attorno allo sterno. Nel frattempo in tutto il mondo numerosi portatori di protesi valvolari “compatibili a esame RM” sono stati sottoposti a esami RM. Finora non sono stati riportati casi di serie complicazioni.

Che cosa occorre comunque osservare?

In primo luogo il medico che invia il paziente ad un esame RM e il medico che esegue tale esame devono assicurarsi che la protesi valvolare sia propriamente in sede prima di procedere.
La forza di deflessione operata dal campo magnetico sulla valvola artificiale è minima se confrontata con le forze espresse dalle contrazioni del muscolo cardiaco; tuttavia anche la minima forza esercitata dal campo magnetico potrebbe essere sufficiente per dare l’ultima “spinta” alla valvola, nel caso in cui ad esempio questa fosse tenuta da un unico filo. Quest’esempio è soltanto una pura considerazione teorica.

Un’ecocardiografia per chiarire la situazione

Nei pazienti che presentano una cattiva emodinamica (fattori che influenzano il flusso ematico nei vasi, ad esempio la pressione del sangue) e in cui si sospetta una notevole disfunzione della valvola cardiaca dovrebbe essere eseguita un’ecocardiografia per chiarire la situazione prima di passare ad un esame RM.

Attenzione alle valvole cardiache costruite prima del 1969

Si raccomanda di non eseguire l’esame RM su portatori di protesi valvolari non verificate per la loro compatibilità RM (costruite prima del 1969). Evitare l’esame RM anche su pazienti appena operati ai cui vasi ematici non sono stati applicati clip in leghe di titanio e tantalio. Per sicurezza è inoltre meglio evitare l’esame RM ai pazienti che presentano corpi estranei metallici penetrati nell’organismo per altra via e posizionati vicino a punti critici. (RK/G.N.)

PD Dr. med. Heinrich Koertke, Heart- and Diabetes-Center, Bad Oeynhausen/Germany (2004)

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