Valvula mitral conroversias

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 48598-675 doi101016jjacc200605030

CIRUGIA EN ESTENOSIS MITRAL

COMISUROTOMIAREEMPLAZO VALVULAR

ANILLO MITRAL CUERDAS TENDINEAS MUSCULOS PAPILARES

CONCEPTOS ANATOMICOS

Figure 1 Carpentierrsquos functional classification Type I normal leaflet motion Type II increased leaflet motion (leaflet prolapse) Type IIIa restricted leaflet motion during diastole and systole Type IIIb restricted leaflet motion predominantly during systole

La enfermedad mitral degenrativa A La enfermedad de Barlow B La degeneracioacuten fibroelaacutestica

ASINTOMATICOS QUE TECNICA USAR COMO MANEJAR CUANDO OPERAR LA ISQUEMIA MITRAL

3 controversias aun sin resolver

Copyright copy2002 American Heart AssociationAvierinos J-F et al Circulation 20021061355-1361

Clinical Investigation and Reports

Natural History of Asymptomatic Mitral Valve Prolapse in the Community Jean-Franccedilois Avierinos MD Bernard J Gersh MB ChB DPhil L Joseph Melton III MD Kent R Bailey PhD Clarence Shub MD Rick A Nishimura MD A Jamil Tajik MD Maurice Enriquez-Sarano MD From the Division of Cardiovascular Diseases (J-FA BJG CS RAN AJT ME-S) Section of Clinical Epidemiology (LJM) and Section of Biostatistics (KRB) Mayo Clinic Rochester Minn

Circulation August 1 2006

ACCAHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

Class III1 MV surgery is not indicated for asymptomatic patients with MR and preserved LV function (ejection fraction greater than 060 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

Class IIa1 MV repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe MR with preserved LV function (ejection fraction greater than 060 and end-systolic dimension less than 40 mm) in whom the likelihood of successful 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)

ACCAHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

No need to rush to surgery in asymptomatic patients with severe mitral Regurgitation MAY 4 2006 |

SOBREVIDA LIBRE DE NECESIDAD DE CIRUGIgraveA

Time (y) Survival free of any indication for surgery ()

2 922

4 784

6 655

8 556

Rosenhek R et al Circulation 2006 1132238-2244

SOBREVIDA A LARGO PLAZO EN ENINSUFICIENCIAMITRAL SEVERA

Conclusions Quantitative grading of mitral regurgitation is a powerful predictor of the clinical outcome of asymptomatic mitral regurgitation Patients with an effective regurgitant orifice of at least 40 mm2 should promptly be considered for cardiac surgery

Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation

Maurice Enriquez-Sarano MD Jean-Franccedilois Avierinos MD David Messika-Zeitoun MD Delphine Detaint MD Maryann Capps RDCS Vuyisile Nkomo MD Christopher Scott MS Hartzell V Schaff MD and A Jamil Tajik MD

EDITORIALTiming of Surgery in Asymptomatic Mitral Regurgitation

Catherine M Otto MD and Christopher T Salerno MD

RIESGO MANEJO MORTALIDAD

MEDICO 26 vs OPERATORIA 1

The New England Journal of medicineVolume 352875-883 March 3 2005 Number 9

Enriquez-Sarano M et al N Engl J Med 2005352875-883

FACTORES DE RIESGO DE MUERTE EN PACIENTES ASINTOMATICOS CON INSUFICIENCIA MITRAL SEVERA NO SINTOAMATICA

Enriquez-Sarano M et al N Engl J Med 2005352875-883

Enriquez-Sarano M et al N Engl J Med 2005352875-883

RIESGO DE MUERTE DE ACUERDO AL AREA DEL ORIFICIO REGURGITANTE (ERO)EN PACIENTES EN MANEJO MEDICO

Enriquez-Sarano M et al N Engl J Med 2005352875-883

SOBREVIDA ( KAPLAN MEIER) EN PACIENTES ASINTOMATICOS DE EN PACIENTES EN MANEJO MEDICO DE ACUERDO AL AREA DEL

ORIFICIO REGURGITANTE (ERO)

However we illustrate here that overwhelmingly coherent cumulative evidence obtained worldwide shows that early surgery should be the preferred management approach for organic MR This approach differs from standard guidelines and it is essential that its principles rationales and conduct be fully considered

Controversies in Cardiovascular Medicine

Is early surgery recommended for mitral regurgitationEarly Surgery Is Recommended for Mitral RegurgitationMaurice Enriquez-Sarano MD Thoralf M Sundt III MD From the Divisions of Cardiovascular Diseases and Internal Medicine (ME-S) and Cardiac Surgery (TMS) Mayo Clinic Rochester Minn

Circulation 2010121804-812

Fraccioacuten de Eyeccioacuten lt 60

Diaacutemetro VI de fin de Diaacutestole gt 65mm

Diaacutemetro VI de fin de Sistole gt 40mm

Hipertensioacuten pulmonar gt 50mmHg

Orificio regurgitante efectivo ERO gt 40mm

Fibrilacioacuten auricular de Novo

CIRUGIA VALVULAR MITRAL

EN PACIENTES ASINTOMATICOS

CONCLUSION

90 EacuteXITO EN PLASTIA VALVULAR MITRAL

Factores a considerar para definir el tiempo ideal de cirugiacutea en vaacutelvula mitral

En pacientes asintomaacuteticos

Anatoacutemicos Eco cardiograacuteficos

Adams D H et al Eur Heart J 2010eurheartjehq222

ACCAHA 2006 Guidelines for the Management of PatientsWith Valvular Heart DiseaseA Report of the American College of CardiologyAmerican Heart AssociationTask Force on Practice Guidelines (Writing Committee to Revise the 1998Guidelines for the Management of Patients With Valvular Heart Disease)

Circulation August 1 2006

MV repair is the operation of choice when the valve is suitable for repair and appropriate surgical skill and expertise are available This procedure preserves thepatientrsquos native valve without a prosthesis and therefore avoids the risk of chronic anticoagulation (except in patients in atrial fibrillation) or prosthetic valve failure late after surgery Additionally preservation of the mitral apparatus leads to better postoperative LV function and survival than in cases in which the apparatus is disrupted In most cases

VS

Class IbullMV surgery is recommended for the symptomatic patient with acute severe MR (Level of Evidence B)

bullMV 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 030) andor end-systolic dimension greaterthan 55 mm (Level of Evidence B)

3 MV surgery is beneficial for asymptomatic patients with chronic severe MR and mild to moderate LV dysfunction ejection fraction 030 to 060 andor end-systolic dimension greater than or equal to 40mm (Level of Evidence B)

4 MV repair is recommended over MV replacement inthe majority of patients with severe chronic MR who require surgery and patients should be referred to surgical centers experienced in MV repair Bonow et al ACCAHA Practice Guidelines (Level ofEvidence C)

ACCAHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

VS

Long-term outcomes after surgery for rheumatic mitral valve disease valve repair versus mechanical valve replacement

Joon Bum Kima Hee Jung Kima Duk Hwan Moona Sung Ho Junga Suk Jung Chooa Cheol Hyun Chunga Hyun Songb Jae Wo Leea

Department of Thoracic and Cardiovascular Surgery Asan Medical Center University of Ulsan College of Medicine 388-1 Pungnap-dong Songpa-gu Seoul 138-736 South Korea

Conclusions When performed for selected patients MV repair had excellent durability comparable to mechanical valve replacement in rheumatic disease Both MV repair and replacement had comparable long-term clinical results therefore repair surgery seems to be more beneficial by avoiding troublesome life-long anticoagulation and risks of bleeding

VS

Eur J Cardiothorac Surg 2010371039-1046

Valve Repair Improves the Outcome of Surgery for Mitral Regurgitation

A Multivariate Analysis Maurice Enriquez-Sarano MD Hartzell V Schaff MD Thomas A Orszulak MD A Jamil Tajik MD Kent R Bailey PhD Robert L Frye MD From the Division of Cardiovascular Diseases and Internal Medicine (ME-S AJT RLF) Section of Cardiovascular Surgery (HVS TAO) and Section of Biostatistics (KRB) 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

VS

Valve repair versus valve replacement for degenerative mitral valve diseasebullMarc Gillinov MDa

Eugene H Blackstone MDab Edward R Nowicki MDa Worawong

Slisatkorn 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

bull Lars G Svensson MD PhDa

(70 )plusmn 12 antildeos (57 )plusmn 13 antildeos5a 10a 15a 5a 10a 15ordf

Sobrevida 83 62 43 86 63 45

Libre de Re operacion

94 94 95 92

J Thorac Cardiovasc Surg 2008135885-893

VS

Valve repair versus valve replacement for degenerative mitral valve diseasebullMarc Gillinov MDa

Eugene H Blackstone MDab Edward R Nowicki MDa Worawong

Slisatkorn 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

bull Lars G Svensson MD PhDa

Conclusion It is reasonable to perform valve repair in elderly patients with complex degenerative mitral valve pathology because it can eliminate the need for anticoagulation and risk of prosthesis-related complications However when valve pathology is so complex that

repair is infeasible this study demonstrates that valve replacement does not diminish long-term outcomes

J Thorac Cardiovasc Surg 2008135885-893

VS

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

Mitral valve replacement versus repair propensity-adjusted survival and quality-of-life analysisJokinen JJ Hippelaumlinen MJ Pitkaumlnen OA Hartikainen JEDepartment 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 does not differ from each other In terms of most quality-of-life variables patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population

The Annals of Thoracic Surgery Volume 84 Issue 2 August 2007 Paes 451-458

REPARO MITRALTECNICAS QUIRURGICAS

HOJUELA POSTERIORRESECCION CUADRANGULAR

TRASPOSICION DE CUERDAS TENDINEAS

REIMPLATE MUSCULO PAPILAR

RESECCION TRIANGULAR

El Reparo Valvular Mitral (RVM) es Superior Al Cambio Valvular Mitral (CVM) Por La Preservacioacuten De Todo El Aparato Sub valvular Que Garantiza La Competencia Mitral Preserva La Funcioacuten Del VI Y Aumenta La Sobrevida

No hay diferencias en tegraverminos de calidad de vida entre las 2 tegravecnicas si no es necesaria la anticoagulacion cronica con warfarina

CIRUGIA VALVULAR MITRAL CAMBIO VS REPARO

CONCLUSION

El efeecto benefico de la PVM versus el CVM en terminos de sobrevida se pierde en pacientes mayores de 70 antildeos por lo que cualquiera de las dos tecnicas utilizadas es aceptable en este grupo de edad

Debe procurarse en todo paciente con CVM la preservacion del aparato subvalvular posterior

CIRUGIA VALVULAR MITRAL CAMBIO VS REPARO

CONCLUSION

CONTROVERSIAS EN CIRUGIacuteA DE

LA VALVULA MITRAL

Dra Moacutenica RenterigraveaCali- Colombia

Reconstruccion tridimensional del anillo mitral

ENFERMEDAD VALVULAR MITRAL DE ORIGEN ISQUEMICO

Remodelacioacuten ventricular izquierda post IAM

COAPSYS DEVICE

CORRECCION PERCUTANEA DE LA INSUFICIENCIA MITRAL

CORRECCION PERCUTANEA DE LA INSUFICIENCIA MITRAL

CLIP MITRAL

Imagen Ecocardiografica antes y despues de

anuloplastia del seno coronario

(C) CARILLON (Cardiac DimensionsKirkland WA) (D) MONARC (Edwards Lifesciences Irvine CA)(E) Percutaneous Transvenous Mitral Annuloplasty Device (Viacor Inc Wilmington MA)

CORRECCION PERCUTANEA DE LA INSUFICIENCIA MITRAL

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)

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)

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)

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 48598-675 doi101016jjacc200605030