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

@docporrasdocporras@gmail.com

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