Measures of Dispersion and Variability: Range, QD, AD and SD
Valvula mitral conroversias
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
5. Figure 1: Carpentier’s 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.*
9. ?
ACC/AHA 2006 Guidelines for the Management of Patients With
Valvular 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
10. ?
ACC/AHA 2006 Guidelines for the Management of Patients With
Valvular Heart Disease.
Class IIa
1. MV repair is reasonable in experienced surgical centers for asymptomatic patients
with chronic severe MR* with preserved LV function (ejection fraction greater than
0.60 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 systolic
pressure greater than 50 mm Hg at rest or greaterthan 60 mm Hg on exercise)
Circulation August 1, 2006
11. No need to rush to surgery in asymptomatic patients with severe mitral
Regurgitation 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.
13. Quantitative Determinants
? of the Outcome of Asymptomatic Mitral Regurgitation
Maurice 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 clinical
outcome of asymptomatic mitral regurgitation. Patients with an effective regurgitant orifice of at
least 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 MORTALIDAD
MEDICO 2,6 % vs OPERATORIA 1%
The New England Journal of medicine:Volume 352:875-883 March 3, 2005 Number 9
14. FACTORES DE RIESGO DE MUERTE EN PACIENTES ASINTOMATICOS CON
INSUFICIENCIA MITRAL SEVERA NO SINTOAMATICA
Enriquez-Sarano M et al. N Engl J Med 2005;352:875-883
Enriquez-Sarano M et al. N Engl J Med 2005;352:875-883
15. 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 2005;352:875-883
16. 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
17. ?
Controversies in Cardiovascular Medicine
Is early surgery recommended for mitral regurgitation?
Early Surgery Is Recommended for Mitral Regurgitation
Maurice Enriquez-Sarano, MD; Thoralf M. Sundt, III, MD
From 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 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.
Circulation. 2010;121:804-812
18. CONCLUSION
CIRUGIA VALVULAR MITRAL
EN PACIENTES ASINTOMATICOS *
Fracción de Eyección < 60%
Diámetro VI de fin de Diástole > 65mm
Diámetro VI de fin de Sistole > 40mm
Hipertensión pulmonar > 50mmHg
Orificio regurgitante efectivo ERO > 40mm
Fibrilación auricular de Novo
* 90% ÉXITO EN PLASTIA VALVULAR MITRAL
19. Factores a considerar para definir el
tiempo ideal de cirugía en válvula mitral
En pacientes asintomáticos
Anatómicos Eco cardiográficos
Adams D H et al. Eur Heart J 2010;eurheartj.ehq222
20. VS.
ACC/AHA 2006 Guidelines for the Management of Patients
With Valvular Heart Disease
A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to Revise the 1998
Guidelines for the Management of Patients With Valvular Heart Disease)
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 the
patient’s 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,
Circulation August 1, 2006
21. VS.
ACC/AHA 2006 Guidelines for the Management of Patients With
Valvular Heart Disease.
Class I
•MV surgery is recommended for the symptomatic patient with acute severe MR.* (Level of
Evidence: 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-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 0.30 to 0.60, and/or 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 ACC/AHA Practice Guidelines (Level
ofEvidence: C)
22. 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.
Eur J Cardiothorac Surg 2010;37:1039-1046
23. VS.
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 (M.E.-S., A.J.T., R.L.F.), Section of
Cardiovascular 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.
24. VS.
Valve repair versus valve replacement for
degenerative mitral valve disease
•Marc Gillinov, MDa,*, Eugene H. Blackstone, MDa,b, 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
•, Lars G. Svensson, MD, PhDa
(70 )± 12 años (57 )± 13 años
5a 10a 15a 5a 10a 15ª
Sobrevida 83% 62% 43% 86% 63% 45%
Libre de 94% 94% 95% 92%
Re operacion
J Thorac Cardiovasc Surg 2008;135:885-893
25. VS.
Valve repair versus valve replacement for
degenerative mitral valve disease
•Marc Gillinov, MDa,*, Eugene H. Blackstone, MDa,b, 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
•, 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 2008;135:885-893
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.
Conclusions
Survival 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
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.
Conclusions
Survival 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
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.
Conclusions
Survival 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
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.
Conclusions
Survival 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
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.
Conclusions
Survival 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
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.
Conclusions
Survival 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
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.
Conclusions
Survival 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
33. 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.
Conclusions
Survival 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
35. CONCLUSION
CIRUGIA VALVULAR MITRAL
CAMBIO VS REPARO
El Reparo Valvular Mitral (RVM) es Superior Al Cambio Valvular
Mitral (CVM) Por La Preservación De Todo El Aparato Sub
valvular Que Garantiza La Competencia Mitral , Preserva La
Función Del VI, Y Aumenta La Sobrevida .
No hay diferencias en tèrminos de calidad de vida entre las 2
tècnicas si no es necesaria la anticoagulacion cronica con
warfarina .
36. CONCLUSION
CIRUGIA VALVULAR MITRAL
CAMBIO VS REPARO
El efeecto benefico de la PVM versus el CVM en terminos de
sobrevida se pierde en pacientes mayores de 70 años 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.
37. ENFERMEDAD VALVULAR MITRAL DE ORIGEN ISQUEMICO
CONTROVERSIAS
EN CIRUGÍA DE
LA VALVULA
MITRAL
Dra. Mónica Renterìa
Cali- Colombia
Reconstruccion tridimensional del anillo mitral
42. 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).
43. tal MS who have mild symptoms (NYHA functional class II) and mean MV gradient gre
h congenital MS with pulmonary artery systolic pressure 50 mm Hg or greater and a m
olescent 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
Notas del editor
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.
