transesophageal echocardiography in percutaneous treatment of mitral insufficiency
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ECOCARDIOGRAFIAEN EL TRATAMIENTO PERCUTANEO
DE LA INSUFICIENCIA MITRAL
Dr. Ricardo Poveda JaramilloFellow Ane!eiaCardiovac"lar
Univeridad CES
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E#idemiolo$%a
La in"&ciencia mi!ral e la e$"nda valv"lo#a!%am' (rec"en!e en n"e!ro medio a #ear de ladimin"ci)n de la &e*re re"m'!ica
Prevalencia en a"men!o Grado moderado o evero e!ar%an #reen!e
en el +,- de #erona maore de /0 a1o La 2i!oria na!"ral de la mima )lo con
!ra!amien!o m3dico e (a!al 4a!a el 0,- de lo #acien!e in!om'!ico
2o#i!ali5ado con IM evera no e in!ervienen6"ir7r$icamen!e
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J"!i&caci)n
Mortalidad1-2%
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Di#oi!ivo #erc"!'neo
Mi!raCli#8
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T3cnica
O!!avioAl&eri9:,,+9Ospedale SanRafaele,
Mil'n9 I!alia
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A la (ec2a;
M' de :,.,,, #acien!e 2an ido!ra!ado a nivel m"ndial
E&cacia del
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Criterios de inclusin
RM in!om'!ica $rado >?@Rie$o de mor!alidad de +:-
Criterios potenciales:
Aor!a en #orcelana
A!eroma m)vil en aor!a acenden!eMedia!ino #o!?radiaci)n
RM ("ncional con (racci)n de eecci)n @,-
Edad B/0 a1o con FEI @,-.
E!erno!om%a mediana an!erior con *#a coronario #revio
Do cir"$%a en !)ra an!eriore
Cirroi 2e#'!ica
Tre de lo cri!erio de al!o rie$o i$"ien!e STS; nivel de crea!inina :90m$dl9 cir"$%a de !)ra an!erior9 edad B/0 a1o 9 o FEI >0-
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Pa#el de la ETE en el im#lan!e del di#oi!ivo Mi!raCli#8
Seleccionar al #acien!e id)neo; cri!erio ana!omo("ncionale
G"iar la in!ervenci)n en el la*ora!orio de 2emodin'mica
Eval"ar el re"l!ado &nal
Dia$no!icar e iden!i&car com#licacione en el #rocedimien!o
Se$"imien!o de lo #acien!e
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+. Seleccionar al #acien!e id)neo;cri!erio ana!omo("ncionale
Cri!erio e!iol)$ico Candida!o id)neo; Pacien!e con IM !i#o III* o ("ncional re!ricci)n de la movilidad i!)lica9 #or
remodelado ven!ric"lar9 en miocardio#a!%a dila!ada o i6"3micaH Pacien!e con IM !i#o II o de$enera!iva9 #or a"men!o en la movilidad de la
valva #rola#oH
Pacien!e con el !i#o I de IM movilidad normal de veloH c"ando la ca"a ea"na dila!aci)n del anillo
No er%an candida!o adec"ado; A6"ello con IM !i#o IIIa o re"m'!ica re!ricci)n i!)lica dia!)lica de
movilidad de la valvaH.
Pacien!e con el !i#o I de IM movilidad normal de veloH c"ando la ca"a ea"na #er(oraci)n valv"lar.
K EEREST; la e!iolo$%a de la IM no e !an im#or!an!e como la carac!er%!icaana!)mica de la v'lv"la a !ra!ar
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:. C"an!i&caci)n de la everidad; E!adiode la re$"r$i!aci)n mi!ral #rimaria
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E!adio de la re$"r$i!aci)n mi!ralec"ndaria
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>. De!erminaci)n de la carac!er%!ica ana!)mica dela v'lv"la el mecanimo de la re$"r$i!aci)n mi!ral
M' 6"e la e!iolo$%a on lacarac!er%!ica ana!)mica de lav'lv"la mi!ral la im#or!an!e a la 2ora
de indicar i "n candida!o e id)neo#ara el #rocedimien!o del Mi!raCli#8
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Mor(olo$%a mi!ral id)nea #ara im#lan!e Mi!raCli#8
Ori$en deljet de IM en la #orci)n medial de la M e!iolo$%a
de$enera!iva o ("ncionalHA"encia de calci&caci)n en M a nivel de la 5ona de a!ra#amien!odel Mi!raCli#8
rea valv"lar mi!ral B @ cm:
Lon$i!"d de velo #o!erior mi!ral +, mm medido en la #roecci)n
de @ c'mara o en la #roecci)n del !rac!o de alida del ven!r%c"loi56"ierdoH
S"&cien!e !eQido de coa#!aci)n en!re am*o velo mi!rale; IM or$'nica;
Se#araci)n en!re am*o velo (fail gap) +, mm medidoen la #roecci)n de @ c'mara ) 0 c'mara o de eQe lar$o deven!r%c"lo i56"ierdoH Anc2"ra #rola#o +0 mm medido en la #roecci)n!ran$'!rica eQe cor!oH
IM ("ncional; Pro("ndidad coa#!aci)n en!re am*o velo ++ mm Lon$i!"d de la coa#!aci)n B : mm
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Mor(olo$%a mi!ral no id)nea #ara im#lan!e Mi!raCli#8
Per(oraci)n o clet del velo mi!ralFal!a de coa#!aci)n de velo en IM ("ncional
Gran #rola#o con ro!"ra de c"erda #rimaria ec"ndaria
Calci&caci)n evera en la 5ona de a!ra#amien!o del Mi!raCli#8oanillo mi!ral
rea mi!ral menor de @ cm:Lon$i!"d de velo #o!erior /?= mm
alva #o!erior m" inm)vil
En(ermedad re"m'!ica de la v'lv"la
En(ermedad de arlow o v'lv"la mioma!oa con $roor de velomaor a 0 mmerr"$a endoc'rdica mi!rale
Endocardi!i ac!iva
Cir"$%a de recon!r"cci)n mi!ral #revia9 ece#!o i )lo e !ra!ara de"n anillo #ro!3ico mi!ral ailado.
Preencia de !rom*o maa
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@S
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@.Si!em'!icadee!"diomedian!
eETEdelcandida!oaMi!raCli#8
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Proeccione adicionale
ii)n del eQe cor!o *aal +0V?@0VH donde ea#recia el e#!o in!era"ric"lar re!roa)r!ico.
Plano de *icava =,V?++,VH vi"ali5'ndoe ele#!o in!era"ric"lar la en!rada de am*a venacava en la a"r%c"la derec2a.
i"ali5aci)n de la vena #"lmonar "#eriori56"ierda el li$amen!o de Mar2all onda en!re,V?>,VH.
W i"ali5aci)n de la vena #"lmonar "#eriorderec2a9 en!re
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La im#or!ancia de la ETE en e!e#rocedimien!o e !al 6"e c"al6"ier
con!raindicaci)n #ara reali5ar el e!"dio
!raneo('$ico9 a% como di&c"l!ade#ara la o*!enci)n de im'$eneecocardio$r'&ca adec"ada
ne"mec!omia9 de!rocardia9 e!c.H9 locon!raindicar%a
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T3cnica
El #rocedimien!o e reali5a *aQo
ane!eia $eneral en la ala de2emodin'mica
Se necei!a in(ormaci)n ana!)mica
m" eac!a
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+. P"nci)n !rane#!al
De*e reali5are en la #orci)n m' "#erior #o!erior del e#!o in!era"ric"lar demanera 6"e el ca!3!er #"eda er
Xeionado diri$ido den!ro de la AI 2aciala M con "n e#acio "&cien!e.
La vii)n ecocardio$r'&ca del e#!o
levan!ado #or el ca!3!er?a$"Qa como "na!ienda de cam#a1a o tenting ae$"ra 6"ee enc"en!ra en el i!io correc!o.
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: d i) d l 3 %
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:. In!rod"cci)n del ca!3!er?$"%aden!ro de la a"r%c"la i56"ierda
El ca!3!er?$"%a con el dila!ador on
in!rod"cido en la AI avan5andoo*re "na $"%a Am#la!5er8e!rarr%$ida i!"ada en la vena
#"lmonar "#erior i56"ierda
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>. Avance del i!ema de li*eraci)n Mi!raCli#8en la a"r%c"la i56"ierda alineaci)n del
di#oi!ivo con la v'lv"la mi!ral
El di#oi!ivo e de*e an$"lar den!ro
de la a"r%c"la i56"ierda "no
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>.
Plano in!ercomi"ral;movimien!o #aracone$"ir "na
alineaci)n m'la!eral P+H o medialP>H.
Plano del !rac!o de
alida del I;alineaci)n an!eriorA:H o #o!erior P:H.
Si!"ar eldi#oi!ivo (ren!e
a la a#er!"ra
valv"lar9o*ervando9
median!e Do##lercolor9 c)mo el
di#oi!ivo divide#or la mi!ad el Qe!re$"r$i!an!e
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>.
Poici)n correc!a;Se vi"ali5an lo : *ra5o del
di#oi!ivo !o!almen!e a*ier!o en la#roecci)n de !rac!o de alida del
ven!r%c"lo i56"ierdo no e vi"ali5an
en a*ol"!o en la #roecci)nin!ercomi"ral
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@ Avance del di#oi!ivo a la
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@. Avance del di#oi!ivo a lacavidad ven!ric"lar
Se reali5a con lo *ra5o del di#oi!ivoa*ier!o
Ima$en Y?Plane in!ercomi"ral !rac!o de
alida de ven!r%c"lo i56"ierdoim"l!'neamen!eH Una ve5 en el ven!r%c"lo9 la orien!aci)n del
cli# de*e er n"evamen!e c2e6"eada El #lano ETE :D !ran$a!rico de eQe cor!o
!am*i3n #ermi!e vi"ali5ar la alineaci)n deldi#oi!ivo
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0 G % d l ! i ! i H d
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0. G"%a del a!ra#amien!o $ra#in$H dela valva #or el di#oi!ivo valoraci)n
de "na a#ro#iada inerci)n
La valoraci)n del adec"ado
a!ra#amien!o de am*o velo den!rodel Mi!raCli#8e de*e reali5ar dede;el #lano del !rac!o de alida del I
velo #o!eriorH el #lano de c"a!ro c'mara velo
an!eriorH
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Z. aloraci)n del re"l!ado IM
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reid"alH li*eraci)n del
di#oi!ivo El #rocedimien!o e conidere e&ca5
%;
La IM reid"al e menor en9 almeno9 "n $rado re#ec!o a la *aal4a a"encia de $radien!e de
llenado i$ni&ca!ivo no m' de 0mm4$ de $radien!e medio eadmii*leH
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[C)mo e 2ace\
?
En cao 6"e #eri!a "na IM
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En cao 6"e #eri!a "na IMi$ni&ca!iva]
Re#oicionamien!o del cli#9 i e #iena6"e #"ede er o#!imi5ado9 )
Colocaci)n de "n e$"ndo di#oi!ivo;
El e$"ndo cli# en la AI de*e avan5ar2acia el I con lo *ra5o cerradoH
El e$"ndo di#oi!ivo de*e er alineado
lo m' #aralelo #oi*le al #rimero lom' #r)imo a 3lLa ETE >D e realmen!e 7!il
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/. Con!rol de la re!irada del ca!3!er?
$"%a
Se$"ir el recorrido invero al de "in!rod"cci)n
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=. Revii)n &nal del #rocedimien!o
O*ervar el e!ado del e#!oin!era"ric"lar9 donde con (rec"encia6"eda "na #e6"e1a com"nicaci)n
con li$ero cor!ocirc"i!o i56"ierda?derec2a
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Com#licacione del im#lan!e
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Com#licacione del im#lan!eMi!raCli#8
Da1o #or el ca!3!er?$"%a en di!in!a e!r"c!"racard%aca; #ared a"ric"lar9 vena #"lmonare9oreQ"ela9 a#ara!o "*valv"lar mi!ral o valva mi!rale
4emo#ericardio !a#onamien!o9 !a6"iarri!mia
"#raven!ric"lare o ven!ric"lare. Em*oli5aci)n del di#oi!ivo P3rdida de &Qaci)n de "no de lo velo valv"lare A!ra#amien!o del di#oi!ivo en!re la c"erda mi!rale
Formaci)n de !rom*o o #rod"cci)n de "n em*olimoa3reo Com"nicaci)n in!era"ric"lar i$ni&ca!iva !ra la
#"nci)n !rane#!al
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Se$"imien!o de #acien!e !ra!ado
con di#oi!ivo Mi!raCli#8
ETT e "&cien!e
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O!ro #rocedimien!o#erc"!'neo #ara el !ra!amien!ode la in"&ciencia mi!ral
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An"lo#la!ia indirec!a v%a eno
coronario
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Gra5ie