Valvula mitral conroversias
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  • Table 1. Baseline Clinical, Left Ventricular, and Hemodynamic Characteristics of Patients with Asymptomatic Mitral Regurgitation.
  • Table 2. Risk of Death from Any Cause, Death from Cardiac Causes, and Cardiac Events among Patients with Asymptomatic Mitral Regurgitation under Medical Management.
  • Figure 1. Kaplan-Meier Estimates of the Mean ({+/-}SE) Rates of Overall Survival among Patients with Asymptomatic Mitral Regurgitation under Medical Management, According to the Effective Regurgitant Orifice (ERO). Values in parentheses are survival rates at five years.

Valvula mitral conroversias Presentation Transcript

  • 1. Mitral Stenosis. Class I MV surgery is indicated in adolescent or young adult patients with congenital MS who have symptoms (NYHA functional class III or IV) and mean MV gradient greater than 10 mm Hg on Doppler echocardiography.* (Level of Evidence: C)Class IIa 1 MV surgery is reasonable in adolescent or young adult patients with congenital MS who have mild symptoms (NYHA functional class II) and mean MV gradient greater than 10 mm Hg on Doppler echocardiography.* (Level of Evidence: C) 2 MV surgery is reasonable in the asymptomatic adolescent or young adult with congenital MS with pulmonary artery systolic pressure 50 mm Hg or greater and a mean MV gradient greater than or equal to 10 mm Hg.* (Level of Evidence: C)Class IIb The effectiveness of MV surgery is not well established in the asymptomatic adolescent or young adult with congenital MS and new-onset atrial fibrillation or multiple systemic emboli while receiving adequate anticoagulation.* (Level of Evidence: C J Am Coll Cardiol, 2006; 48:598-675, doi:10.1016/j.jacc.2006.05.030
  • 2. CIRUGIA EN ESTENOSIS MITRALCOMISUROTOMIA REEMPLAZO VALVULAR
  • 3. CONCEPTOS ANATOMICOSANILLO MITRAL CUERDAS TENDINEAS MUSCULOS PAPILARES
  • 4. Figure 1: Carpentier’s functional classification. Type I, normal leafletmotion;Type II, increased leaflet motion (leaflet prolapse);Type IIIa restricted leaflet motion during diastole and systole;Type IIIb restricted leaflet motion predominantly during systole.*
  • 5. La enfermedad mitraldegenrativa. A, Laenfermedad de Barlow;B, La degeneraciónfibroelástica
  • 6. 3 controversias aun sin resolver ASINTOMATICOS QUE TECNICA USAR COMO MANEJARCUANDO OPERAR? LA ISQUEMIA MITRAL
  • 7. Natural History of Asymptomatic Mitral Valve Prolapse in the Community ; Bernard J. Gersh, MB, ChB, DPhil; L. Joseph Melton,Jean-François Avierinos, MDIII, MD; Kent R. Bailey, PhD; Clarence Shub, MD; Rick A. Nishimura,MD; A. Jamil Tajik, MD; Maurice Enriquez-Sarano, MDFrom the Division of Cardiovascular Diseases (J.-F.A., B.J.G., C.S., R.A.N., A.J.T., M.E.-S.), Section of Clinical Epidemiology (L.J.M.), and Section of Biostatistics (K.R.B.), Mayo Clinic, Rochester, Minn. Clinical Investigation and Reports Copyright ©2002 American Heart AssociationAvierinos, J.-F. et al. Circulation 2002;106:1355-1361
  • 8. ?ACC/AHA 2006 Guidelines for the Management of Patients WithValvular Heart Disease. Class III 1. MV surgery is not indicated for asymptomatic patients with MR and preserved LV function (ejection fraction greater than 0.60 and end-systolic dimensionless than 40 mm) in whom significant doubt about the feasibility of repair exists. (Level of Evidence: C) 2. Isolated MV surgery is not indicated for patients withmild or moderate MR. (Level of Evidence: C)Circulation August 1, 2006
  • 9. ?ACC/AHA 2006 Guidelines for the Management of Patients WithValvular Heart Disease.Class IIa1. MV repair is reasonable in experienced surgical centers for asymptomatic patientswith chronic severe MR* with preserved LV function (ejection fraction greater than0.60 and end-systolic dimension less than 40 mm) in whom the likelihood ofsuccessful repair without residual MR is greater than 90%.(Level of Evidence: B)2. MV surgery is reasonable for asymptomatic patients with chronic severe MR,*preserved LV function, and new onset of atrial fibrillation. (Level of Evidence: C)3. MV surgery is reasonable for asymptomatic patients with chronic severe MR,*preserved LV function, and pulmonary hypertension (pulmonary artery systolicpressure greater than 50 mm Hg at rest or greaterthan 60 mm Hg on exercise)Circulation August 1, 2006
  • 10. No need to rush to surgery in asymptomatic patients with severe mitralRegurgitation MAY 4, 2006 | SOBREVIDA LIBRE DE NECESIDAD DE CIRUGÌA Time (y) Survival free of any indication for surgery (%) 2 92.2 4 78.4 6 65.5 8 55.6 Rosenhek R et al. Circulation 2006; 113:2238-2244.
  • 11. SOBREVIDA A LARGO PLAZO EN ENINSUFICIENCIA MITRAL SEVERA
  • 12. Quantitative Determinants ? of the Outcome of Asymptomatic Mitral RegurgitationMaurice Enriquez-Sarano, M.D., Jean-François Avierinos, M.D., David Messika-Zeitoun, M.D., Delphine Detaint,M.D., Maryann Capps, R.D.C.S., Vuyisile Nkomo, M.D., Christopher Scott, M.S., Hartzell V. Schaff, M.D., and A.Jamil Tajik, M.D.Conclusions Quantitative grading of mitral regurgitation is a powerful predictor of the clinicaloutcome of asymptomatic mitral regurgitation. Patients with an effective regurgitant orifice of atleast 40 mm2 should promptly be considered for cardiac surgery. EDITORIAL Timing of Surgery in Asymptomatic Mitral Regurgitation Catherine M. Otto, M.D., and Christopher T. Salerno, M.D.RIESGO MANEJO MORTALIDADMEDICO 2,6 % vs OPERATORIA 1%The New England Journal of medicine:Volume 352:875-883 March 3, 2005 Number 9
  • 13. FACTORES DE RIESGO DE MUERTE EN PACIENTES ASINTOMATICOS CON INSUFICIENCIA MITRAL SEVERA NO SINTOAMATICA Enriquez-Sarano M et al. N Engl J Med 2005;352:875-883Enriquez-Sarano M et al. N Engl J Med 2005;352:875-883
  • 14. RIESGO DE MUERTE DE ACUERDO AL AREA DEL ORIFICIO REGURGITANTE (ERO)EN PACIENTES EN MANEJO MEDICOEnriquez-Sarano M et al. N Engl J Med 2005;352:875-883
  • 15. SOBREVIDA ( KAPLAN MEIER) EN PACIENTES ASINTOMATICOS DE EN PACIENTES EN MANEJO MEDICO DE ACUERDO AL AREA DEL ORIFICIO REGURGITANTE (ERO)Enriquez-Sarano M et al. N Engl J Med 2005;352:875-883
  • 16. ? Controversies in Cardiovascular MedicineIs early surgery recommended for mitral regurgitation?Early Surgery Is Recommended for Mitral RegurgitationMaurice Enriquez-Sarano, MD; Thoralf M. Sundt, III, MDFrom the Divisions of Cardiovascular Diseases and Internal Medicine (M.E.-S.)and Cardiac Surgery (T.M.S.), Mayo Clinic, Rochester, Minn.However, we illustrate here that overwhelmingly coherent cumulativeevidence obtained worldwide shows that early surgery should be the preferredmanagement approach for organic MR. This approach differs from standardguidelines, and it is essential that its principles, rationales, and conduct be fullyconsidered.Circulation. 2010;121:804-812
  • 17. CONCLUSION CIRUGIA VALVULAR MITRAL EN PACIENTES ASINTOMATICOS *Fracción de Eyección < 60%Diámetro VI de fin de Diástole > 65mmDiámetro VI de fin de Sistole > 40mmHipertensión pulmonar > 50mmHgOrificio regurgitante efectivo ERO > 40mmFibrilación auricular de Novo * 90% ÉXITO EN PLASTIA VALVULAR MITRAL
  • 18. Factores a considerar para definir el tiempo ideal de cirugía en válvula mitral En pacientes asintomáticos Anatómicos Eco cardiográficosAdams D H et al. Eur Heart J 2010;eurheartj.ehq222
  • 19. VS.ACC/AHA 2006 Guidelines for the Management of PatientsWith Valvular Heart DiseaseA Report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Writing Committee to Revise the 1998Guidelines for the Management of Patients With Valvular Heart Disease)MV repair is the operation of choice when the valve is suitable for repair andappropriate surgical skill and expertise are available. This procedure preserves thepatient’s native valve without a prosthesis and therefore avoids the risk of chronicanticoagulation (except in patients in atrial fibrillation) or prosthetic valve failurelate after surgery.Additionally, preservation of the mitral apparatus leads to better postoperative LVfunction and survival than in cases in which the apparatus is disrupted In most cases,Circulation August 1, 2006
  • 20. VS.ACC/AHA 2006 Guidelines for the Management of Patients WithValvular Heart Disease.Class I•MV surgery is recommended for the symptomatic patient with acute severe MR.* (Level ofEvidence: B)•MV surgery is beneficial for patients with chronic severe MR* and NYHA functional class II,III, or IVsymptoms in the absence of severe LV dysfunction(severe LV dysfunction is defined as ejection fractionless than 0.30) and/or end-systolicdimension greaterthan 55 mm. (Level of Evidence: B)3. MV surgery is beneficial for asymptomatic patients with chronic severe MR* and mild tomoderate LV dysfunction, ejection fraction 0.30 to 0.60, and/or end-systolic dimensiongreater than or equal to 40mm. (Level of Evidence: B)4. MV repair is recommended over MV replacement inthe majority of patients withsevere chronic MR* who require surgery, and patients should be referred to surgicalcenters experienced in MV repair. Bonow et al ACC/AHA Practice Guidelines (LevelofEvidence: C)
  • 21. VS.Long-term outcomes after surgery for rheumatic mitral valvedisease: valve repair versus mechanical valve replacementJoon Bum Kima, Hee Jung Kima, Duk Hwan Moona, Sung Ho Junga, Suk Jung Chooa, Cheol Hyun Chunga, Hyun Songb, Jae Wo Leea,* Department of Thoracicand Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1Pungnap-dong Songpa-gu, Seoul 138-736, South KoreaConclusions: When performed for selected patients, MV repair hadexcellent durability comparable to mechanical valve replacement inrheumatic disease. Both MV repair and replacement had comparablelong-term clinical results;therefore, repair surgery seems to be more beneficial by avoidingtroublesome life-long anticoagulation and risks of bleeding.Eur J Cardiothorac Surg 2010;37:1039-1046
  • 22. VS.Valve Repair Improves the Outcome of Surgery for MitralRegurgitationA Multivariate AnalysisMaurice Enriquez-Sarano, MD; Hartzell V. Schaff, MD; Thomas A. Orszulak, MD; A.Jamil Tajik, MD; Kent R. Bailey, PhD; Robert L. Frye, MDFrom the Division of Cardiovascular Diseases and Internal Medicine (M.E.-S., A.J.T., R.L.F.), Section ofCardiovascular Surgery (H.V.S., T.A.O.), and Section of Biostatistics (K.R.B.), Mayo Clinic and Mayo Foundation,Rochester, Minn Conclusions Valve repair significantly improves postoperative outcome in patients with mitral regurgitation and should be the preferred mode of surgical correction. The low operative mortality is an incentive for early surgery before ventricular dysfunction occurs.
  • 23. VS.Valve repair versus valve replacement fordegenerative mitral valve disease•Marc Gillinov, MDa,*, Eugene H. Blackstone, MDa,b, Edward R. Nowicki, MDa, WorawongSlisatkorn, MDa, Ghannam Al-Dossari, MDa, Douglas R. Johnston, MDa, Kristopher M. George,MDa, Penny L. Houghtaling, MSb, Brian Griffin, MDc, Joseph F. Sabik, III, Mda•, Lars G. Svensson, MD, PhDa (70 )± 12 años (57 )± 13 años 5a 10a 15a 5a 10a 15ªSobrevida 83% 62% 43% 86% 63% 45%Libre de 94% 94% 95% 92%Re operacionJ Thorac Cardiovasc Surg 2008;135:885-893
  • 24. VS.Valve repair versus valve replacement fordegenerative mitral valve disease•Marc Gillinov, MDa,*, Eugene H. Blackstone, MDa,b, Edward R. Nowicki, MDa, WorawongSlisatkorn, MDa, Ghannam Al-Dossari, MDa, Douglas R. Johnston, MDa, Kristopher M. George,MDa, Penny L. Houghtaling, MSb, Brian Griffin, MDc, Joseph F. Sabik, III, Mda•, Lars G. Svensson, MD, PhDaConclusion: It is reasonable to perform valve repair in elderly patients with complexdegenerative mitral valve pathology because it can eliminate the need for anticoagulation andrisk of prosthesis-related complications. However, when valve pathology is so complex thatrepair is infeasible, this study demonstrates that valve replacement does not diminish long-termoutcomes.J Thorac Cardiovasc Surg 2008;135:885-893
  • 25. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 26. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 27. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 28. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 29. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 30. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 31. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 32. Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.Jokinen JJ, Hippeläinen MJ, Pitkänen OA, Hartikainen JE.Department of Cardiothoracic Surgery, Helsinki University Hospital, Helsinki, Finland.ConclusionsSurvival is longer after MVP than after MVR. The quality of life of MVP and MVR patients doesnot differ from each other. In terms of most quality-of-life variables, patients who undergomitral valve operations cope similarly to an age- and sex-matched reference population. Onlythe scores reflecting energy and mobility were lower in the patients who were operated onthan in the reference populationThe Annals of Thoracic Surgery Volume 84, Issue 2, August 2007, Paes 451-458
  • 33. REPARO MITRAL TECNICAS QUIRURGICAS RESECCION TRIANGULAR REIMPLATE MUSCULO PAPILARHOJUELA POSTERIORRESECCION CUADRANGULAR TRASPOSICION DE CUERDAS TENDINEAS
  • 34. CONCLUSION CIRUGIA VALVULAR MITRAL CAMBIO VS REPAROEl Reparo Valvular Mitral (RVM) es Superior Al Cambio ValvularMitral (CVM) Por La Preservación De Todo El Aparato Subvalvular Que Garantiza La Competencia Mitral , Preserva LaFunción Del VI, Y Aumenta La Sobrevida .No hay diferencias en tèrminos de calidad de vida entre las 2tècnicas si no es necesaria la anticoagulacion cronica conwarfarina .
  • 35. CONCLUSION CIRUGIA VALVULAR MITRAL CAMBIO VS REPAROEl efeecto benefico de la PVM versus el CVM en terminos desobrevida se pierde en pacientes mayores de 70 años por lo quecualquiera de las dos tecnicas utilizadas es aceptable en estegrupo de edadDebe procurarse en todo paciente con CVM la preservacion delaparato subvalvular posterior.
  • 36. ENFERMEDAD VALVULAR MITRAL DE ORIGEN ISQUEMICO CONTROVERSIAS EN CIRUGÍA DE LA VALVULA MITRAL Dra. Mónica Renterìa Cali- Colombia Reconstruccion tridimensional del anillo mitral
  • 37. Remodelación ventricular izquierda post IAM
  • 38. CORRECCION PERCUTANEA DE LA INSUFICIENCIA MITRAL COAPSYS DEVICE
  • 39. CORRECCION PERCUTANEA DE LA INSUFICIENCIA MITRAL CLIP MITRAL
  • 40. CORRECCION PERCUTANEA DE LA INSUFICIENCIA MITRAL Imagen Ecocardiografica antes y despues de anuloplastia del seno coronario (C) CARILLON (Cardiac Dimensions, Kirkland, WA). (D) MONARC (Edwards Lifesciences, Irvine, CA). (E) Percutaneous Transvenous Mitral Annuloplasty Device (Viacor Inc., Wilmington, MA).
  • 41. tal MS who have mild symptoms (NYHA functional class II) and mean MV gradient greh congenital MS with pulmonary artery systolic pressure 50 mm Hg or greater and a molescent or young adult with congenital MS and new-onset atrial fibrillation or multipl J Am Coll Cardiol, 2006; 48:598-675, doi:10.1016/j.jacc.2006.05.030