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