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Cirugíacoronaria
CirugíavalvularEstenosisaórticaInsuficienciaaórticaInsuficienciamitralfuncional
Restauraciónventricular
Resincronización cardiaca(TRC)
Trasplantecardiaco
Asistenciaventricular(LVAD,RVAD,BiVAD)ycorazónartificial
Dispositivosdecontención
Otros
Cirugía coronaria
Beneficios:
Mejoralossíntomas
Mejoralafunciónventricular
Mejoralasupervivencia¿?
Sinsíntomas 1año 5añosAngina 98% 81%Disnea 78% 47%
Myocardialrevascularizationforthetreatmentofpost-ischemicheartfailurePaganoetal.Curr Opin Cardiol 1999
Cirugía coronaria – Síntomas
Media del 8 - 10 %
Cuando:- Miocardio viable >25%- VTS < 130ml- Geometría normal del VI
6 -12 meses
Arend etal.NEJM2007DeBonis etalSurgeryinsightNatClin Pract Cardiovasc Med2006
Cirugía coronaria – función ventricular
“DUKEsdatabank”CABGvsTTO.MÉDICOdurante 25años
Años CABG TTO. MÉDICO
1 83% 74% P<0.0001
5 61% 37% P<0.0001
10 42% 13% P<0.0001
A25-yearexperiencefromtheDukeCardiovascularDiseaseDatabankO'ConnorCMetal.AmJCardiol 90:101,2002
Cirugía coronaria – supervivencia
STICH(SurgicalTreatmentofIschemicHeartFailure)
Coronary-ArteryBypassSurgeryinPatientswithLeftVentricularDysfunctionVelazquezetal.NEngl JMed2011
Cirugía coronaria – supervivencia
STICH(SurgicalTreatmentofIschemicHeartFailure)
Coronary-ArteryBypassSurgeryinPatientswithLeftVentricularDysfunctionVelazquezetal.NEngl JMed2011
Cirugía coronaria – supervivencia
Cirugía coronaria – supervivencia
SeexcluyeronlospacientesconenfermedaddeTCIyCCS3y4
“Intention totreat”Igualmortalidada6añosMenormortalidadCVenCABGMenoreshospitalizacionesporICparaCABG
”Astreated”17%“cross over”deTto.MédicoaCABGMenormortalidadenCABG
Long-term survival ofpatients with ischemic cardiomyopathy treated by CABGvsmedicaltherapyVelazquez etal.AnnThorac Surg 2012
Cirugía coronaria – supervivencia
Coronary-ArteryBypassSurgeryinPatientswithLeftVentricularDysfunctionVelazquezetal.NEngl JMed2011
Elriesgo ylaindicación dependen de:Lechos distales yrevascularización completaViabilidad ¿?Función delVDNYHAyCCSPresión TDVIEdadComorbilidades (arteriopatía perif.ycerebral;EPOC)
CABGforischemiccardiomyopathy.Pocar etal.AnnThorac Surg 2007OutcomeofpatientsinlowEFafterCABG.Hillisetal.Circulation2006
Cirugía coronaria – riesgo /selección depacientes
Mortalidad 2-10%
CABG Tronco I C
CABG Multivaso I B
CABG / PCI Miocardio viable IIa B
PCI Miocardio viable y CABG no indicado IIb C
Cirugía coronaria – guías
2014ESC/EACTSGuidelines on myocardial revascularizationEuropean Heart Journal 2014
Cirugía valvular
Enfermedad valvular queproducedisfunción ventricular
Enfermedad ventricularqueproducedisfunción valvular
Cirugía valvular – estenosis aórtica
Si el gradiente medio es >40 mmHg, teóricamente no hay ningún límite inferiorde FE para el reemplazo valvular aórtico en pacientes con estenosis aórticasevera sintomática
Sin embargo, la recuperación de la función del VI sólo es probable cuando elmotivo de la disfunción ventricular es el exceso de postcarga y no la fibrosismiocárdica
ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure2012.McMurray etal.EuropeanHeartJournal2012
Cirugía valvular – estenosis aórtica
Reservacontráctil
pronósticoalargoplazomortalidadoperatoria
II Simposio Internacionalde Insuficiencia Cardiaca Avanzada
“Valvulopatias en pacientes con mala función ventricular, cirugía o trasplante”
Eco- dobutamina
No↑Gradientes
↑Area valvular
Reservacontráctil
PseudoEstenosis Aórtica
Cirugía valvular – estenosis aórtica
ImprovedoutcomesafterAVRinARwithLVDBhudia etal.JACC2007
LVD improved progressively and by about 1985 was com-parable with that of patients with nonsevere LVD; hospitalmortality decreased to a comparable value. Early and latesurvival was already good and did not change appreciablyover the experience in patients with better LV function.
Furthermore, severe LV dysfunction was associated withextremely enlarged ventricles and large volumes, with meanLV diastolic dimension of 7.5 cm and end-systolic dimen-sion of 5.9 cm, as noted in Appendix A. Tables 1 and 2present other markers for high-risk patients. Clinicians
should be aware that patients with these characteristics canrecover after surgery.Implications for therapy. Guidelines for managing pa-tients with AR and normal LV function generally are clear,but for patients with severe LVD, they reflect conflictingevidence because the results of surgery have historically beenpoor (19). It is recommended that patients with AR and inNew York Heart Association functional class III or IV withpreserved LV function, those in functional class II withprogressive LV dilation or angina, and asymptomatic pa-
Figure 2 Hospital Mortality in Propensity-MatchedPatients Across the Clinical Experience
Solid lines are parametric trend lines enclosed within dashed 68% confidencelimits. Aggregated raw mortality is represented by symbols (squares for severeLVD�group�and�circles�for�the�nonsevere�group).�Abbreviations�as�in�Figure�1.
Figure 3 Ten-Year Predicted Survival in Propensity-Matched Patients According to Date of Operation
Data derived from a multivariable model containing group (severe vs. nonse-vere LVD), date of operation, and interaction of group with date of operation.Solid lines represent parametric estimates enclosed within 68% confidencelimits.�Abbreviations�as�in�Figure�1.
Figure 4 Survival in Propensity-MatchedPatients Undergoing Surgery in 1985 and Beyond
Depiction�is�as�in�Figure�1A.�Solid�lines�represent�predicted�survival�obtainedfor each matched patient by solving the overall, multivariable risk-adjustedequation in Table 3. They are enclosed within 68% confidence limits. Abbrevia-tions�as�in�Figure�1.
Risk Factors for Mortality in the Entire Group
Table 3 Risk Factors for Mortality in the Entire Group
Factor Coefficient ! SE p Value
Early hazard phase
Severe LV dysfunction 1.19 ! 0.49 0.01
Earlier date of operation "0.101 ! 0.021 #0.0001
And LV dysfunction* "0.042 ! 0.043 0.3
Older age† 0.62 ! 0.16 #0.0001
Thoracic aneurysm 0.59 ! 0.27 0.03
Presence of mitral regurgitation 0.66 ! 0.28 0.02
Propensity score "0.11 ! 0.67 0.9
Late hazard phase
Severe LV dysfunction 2.5 ! 0.88 0.004
Older age
In nonsevere LV dysfunction group‡ 0.85 ! 0.12 #0.0001
In severe LV dysfunction group§ 0.18 ! 0.26 0.5
RCA disease (any) 0.65 ! 0.22 0.004
Higher BUN¶ 0.17 ! 0.036 #0.0001
Propensity score 1.7 ! 0.46 0.0003
*Equivalently, this and the previous factor can be considered as separate subgroups, with earlierdate of operation representing nonsevere patients (interaction) and earlier date in the severedysfunction group as "0.14 ! 0.041, p $ 0.0004. †Exp(age/50). ‡Exp(age/50) in nonsevere LVdysfunction group (interaction term). §Exp(age/50) in severe LV dysfunction group (interactionterm). ¶(BUN/20)2, squared transformation.
RCA $ right coronary artery; other abbreviations as in Table 2.
1469JACC Vol. 49, No. 13, 2007 Bhudia et al.April 3, 2007:1465–71 Surgery for Aortic Regurgitation and LV Dysfunction
Cirugía valvular – insuficiencia aórtica
“For some, heart transplantation has been consideredbecause of perceived high perioperative mortality andpoor late survival after aortic valve surgery. However,we have shown in this study that aortic valve surgeryin patients with chronic AR and cardiomyopathy is nolonger a high - risk procedure for which TxCo is abetter option”
Cirugía valvular – insuficiencia aórtica
Cirugía valvular – insuficiencia mitral
DistorsiónyDilataciónanular
Pérdidadelamorfologíaensillademontar(“saddleshape”)
Grigioni et al. Ischemic mitral regurgitation. Long-term outcome and prognostic implications with quantitative doppler assesment. Circulation 2001
Ischemic mitralregurgitation:long-term outcome andprognostic implications withquantitative Doppler assessment.Grigioni etal.Circulation 2001
Cirugía valvular – insuficiencia mitral
Cirugía valvular – insuficiencia mitral
FE > 30% + CABG Severa I C
FE > 30% + CABG Moderada IIa C
FE < 30% + CABG Severa sintomática IIa C
FE < 30% Dilatada o No revascularizable ¿?
Guidelines on the management ofvalvularheart diseaseVahanian etal.European Heart Journal 2012
Cirugía valvular – insuficiencia mitral
Surgical ventricularrestoration inthe treatment ofcongestive heart failure due topost-infarction ventriculardilation.RESTOREgroup.Athanasuleas etal.JACC2004
Cirugía derestauración ventricular
Elobjetivodelaoperaciónesreduciralmenosun30%elVolumenTSdelVI(sindejarunVIdemasiadopequeño)
1198pacientes postIAMycondisfunción ventricular
Mortalidad del5.3%Supervivencia a5años 68%
Variable Preoperatorio PostoperatorioVTSVI 80 ml/m2 56 ml/m2
FE 29% 39%NYHA 67%(III) 87%(I– II)
Cirugía derestauración ventricular
CABG+restauraciónvs
CABGaislado
Coronary BypassSurgery with or without Surgical VentricularReconstructionJonesetal.NEngl JMed 2009
P=0.70
P=0.84
− Lareducción mediadelvolumen TSfue del19%− 13%delos pacientes notenían infarto previo ysólo el50%tenían aquinesia− Larestauración es más útil si elVTS>60ml/m2pero nosereporta elvolumen preop.
− 96centros con5casos /centro− Semodificaron los criterios deinclusión amediados delestudio− etc
ElSTICHtrialnosirvió paratestar lahipótesis
The STICHtrial:misguided conclusionsBuckberg etal.JThorac Cardiovasc Surg 2009
Cirugía derestauración ventricular
Dispositivos de“contención”
“Mallasexternas”Acorn corcap ®
Evitarelremodeladoventricular
Globalsurgical experience with the Acorn cardiac support deviceOzetal.JThorac Cardiovasc Surg 2003
Mortalidad 25.7%(corcap)vs27.0%(control)
FDAdenegada
Estimulación delos baroreceptores carotídeos
Baroreflex activation therapy for the treatment ofheart failure with areduced ejectionfraction:safetyandefficacy inpatients with andwithout cardiac resynchronization therapyZile MRetal.Eur JHeart Fail 2015
Estimulación delos baroreceptores carotídeos
Estimulación delos baroreceptores carotídeos
Mejoralafunciónventricular
MejoralacapacidaddeesfuerzoylaQoL
Disminuyelashospitalizaciones
Mejoralafunciónrenal
Induceremodeladoventricular
Noprovocahipotensiones
Baroreflex activation therapy for the treatment ofheart failure with areduced ejectionfraction:safetyandefficacy inpatients with andwithout cardiac resynchronization therapyZile MRetal.Eur JHeart Fail 2015
CONCLUSIONES:¿Eslacirugíaunaporte?
Lacirugíaaportasolucionesalpacientecondisfunciónventricularsevera
Lacirugíacoronariamejoralafunciónventricular,lossíntomasyprobablementelasupervivencia
Lacirugíavalvularaórticaestáindicadacasisiempretantoesestenosiscomoeninsuficiencia
Lacirugíavalvularmitralestáprobablementeindicadaperoestállenadeincógnitas
Lacirugíaderestauraciónventricularprobablementeestáinfraindicada
Lacirugíasobrelosbaroreceptores carotídeos esprometedora
Phenotypic differences between male physicians, surgeons, and film stars: comparative study.Trilla et al. BMJ 2006
CONCLUSIONES - ¿Qué aporta lacirugía?
Loscirujanossonmásguaposquelosinternistas