Cirugía cardiaca

Cirugía Cardiaca
Actualizacion 2011
Dr. Alberto Forteza
Hospital 12 de Octubre, Madrid
Cirugía Coronaria
Cirugía valvular
TAVI
Cirugía coronaria en España
en 2011. Conclusiones
1. Cirugía en descenso.
2. Pacientes con morbilidad elevada.
3. Incumplimiento continuo de las guías.
4. No exposición de resultados.
PROPORTION CABG 1999-2008
TRENDS IN MORTALITY 1995-2008
MORTALITY ONCAB vs OPCAB
Número
Mortalidad
OPCAB
41 117
1,4%
ONCAB
160 593
2,6%
¿Qué no ha cambiado en cirugía cardiaca durante
el último año?
España, a la cola de Europa…
… en volumen de procedimientos de revascularización
quirúrgica
ESPAÑA. Nº CIRUGIAS CORONARIAS /AÑO
2001-2008 ∆: -13,7%
REGISTRO SECTCV.
www.sectcv.es
114 / M habitante
OPCAB:27.0%
ONCAB:73%
Registro Oficial SECTCV. 2008
¿Causas?
J F Diaz et al Rev Esp Cardiol 2010; 63:1304-16
CRITERIOS UE
Guidelines on myocardial revascularization
The Task force on myocardial revascularization of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (EACTS)
Conclusiones
Cirugía coronaria 2011 en
España
1. Ultimo país de Europa en % Cirugía Coronaria.
2. Penúltimo país con Euroscore log.mas alto (4%).
3. Mortalidad > media, pero ajustada Euroscore.
4. Incumplimento continuo de las guías.
5. No exposición de resultados.
¿QUE HACER?

Cirugía coronaria debe ser arterial.

Disminuir morbilidad, mortalidad, estancia

Exposición pública de resultados por hospital y cirujano

Exigir que se apliquen las guías.


ESC/EACTS/EAPCI. Aspectos legales.
SECTCCV Y EACTS: Defender las indicaciones actuales
de la cirugía coronaria.
Cirugía Coronaria
Cirugía valvular
TAVI
Válvula aórtica bicúspide
BAV es la más frecuente de las
cardiopatías congénitas: 0.5-2%
 Varones (3:1).

Bicuspid aortic valve and ascending aorta
Prevalence of dilation
Author
n
Age
valvulopathy
Aorta
Prevalence
(%)
Pachulski1 101
Adult
Normal or mild
AoE
VS
58
Hahn2
19
Adult
Normal
AA
50
Hahn2
27
Adult
AoI
VS
78
Nistri3
66
17-19
Normal
AA
44
Ferencik y
Pape4
68
15-71
Normal,AoE and
AoI
AA
49
Cecconi5
39
> 40
Normal or mild AoI
AA
77
1.
2.
3.
4.
5.
Am J Cardiol 1991;67:781-782
J Am Coll Cardiol 1992;19:283-288
Heart 1999; 82:19-22
Am J Cardiol 2003;92:43-46
Am J Cardiol 2005; 95:292-294
Cuando debemos remplazar la aorta?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
< 4 cm
4-4.4 cm
4.5-4.9 cm
J Thorac Cardiovasc Surg 2004;128:677
JAMA, September 14, 2011—Vol 306, No. 10 1107
27% cirugía
valvular
o deptes-año
la aorta
3.1 casos
/ 10.000
47%
algún
depoblación
Iao
( vs 0.2
-0.3grado
…en la
general)
26%
aneurisma de aorta
JAMA, September 14, 2011—Vol 306, No. 10 1107
Próximas guías
Cirugía > 55 mm
JAMA 2008; 300 (11) : 1317
Opciones quirúrgicas
60% alguna complicación
mayor relacionada con la Vao
Aortic valve repair
Free from complications
86%
Incidence of valverelated complications
Shaffer et al, EJCTS 2010
Hammermeister et al, JACC 2000
Reparación valvular
aórtica
Si ofrece buena durabilidad es una
buena solución para pacientes adultos
jóvenes
Freedom from recurrent AoR and reop 5, yrs 88 % and 92 %
For type 3
Freedom from recurrent AoR and reop 5, yrs 76 % and 84 %
Functional Classification
Functional classification of aortic root/valve abnormalities and their correlation
with etiologies and surgical procedures El Khoury et All Curr Opin Cardiol. 2005
Mar;20(2):115-21
Qué válvulas pueden ser reparadas?
-
Prolapso
Anillo, Valsalva s, ST junction
Durabilidad
Patología
velos
+
Surgical techniques
Tipo Ib: valsalva sinuses dilation
Remodeling, Yacoub
Reimplantation, David
415 aortic root and arch aneurysms
182 patients aortic valve sparing
operations
150 David operation
Bicuspid valve
0
27
Results
Forteza A et al. Rev Esp Cardiol. 2011;64(6):470–475
Free from reoperation
Bicuspid aortic valve
reoperation, aortic regurgitation, endocarditis
survival
Válvula aórtica bicúspide. Conclusiones
• Supervivencia similar a la población general
• Individualizar indicación entre 50 – 55 mm
• La reparación es posible
• Mejoría calidad de vida en pacientes jóvenes
• Riesgo bajo de complicaciones
Cirugía Coronaria
Cirugía valvular
TAVI
Dr Michael Mack (Medical City Dallas Hospital, TX), a surgeon and
PARTNER investigator, characterized the trial as "a win for
everybody. Surgery looked good; transcatheter-valve replacement
looked good."
Dr John Webb (St Paul's Hospital, Vancouver, BC) one of the early
percutaneous-valve pioneers.
"This is a trial of a first-generation transcatheter-valve system, and
with operators, many of whom had only done two cases before doing this
trial, compared with the very best surgeons, at the very best sites in
the United States--a very high bar. And [the patients enrolled] were
really just the top 10% of surgical candidates-- the worst patients.
Despite that, you have a mortality rate that's lower [numerically] with
transcatheter-valve implantation. The study was powered as a
noninferiority trial, and it met that benchmark."
Dr Michael Mack (Medical City Dallas Hospital, TX),
a surgeon and PARTNER investigator,
"What we have learned through this trial is that there are clearly patients
who are not candidates for surgery now who can be helped by this, but we've
also learned that there is a ceiling to this, and not everybody is a candidate
for transcatheter-valve therapy. I think we have found through both trials,
A and B, that there were patients that we enrolled early on that we would
not enroll today, because they were too old, too frail, or too debilitated, and
they can't even withstand a transcatheter procedure.“
"I also think that, as great as the results for cohort B were, and as great as
these results are from cohort A, you still have a therapy in which between
25% to 35% of patients are dead at one year. So you have to ask, is that an
appropriate use of expensive technology?"
Dr Michael Mack (Medical City Dallas Hospital, TX),
a surgeon and PARTNER investigator,
"We really need to be more selective about who we think has the
greatest chance of surviving one, two, three, and five years out. I would
be disappointed if, in the next series, the one-year survival doesn't
climb up to 80%, 85%, and 90%.“
"If you look at the one-year survival of all patients undergoing valvereplacement surgery in the US today, it's 93%. So I think that's the
target to aim for."
Cirugía Cardiaca
Actualizacion 2011
Dr. Alberto Forteza
Hospital 12 de Octubre, Madrid