Entrevista con los Expertos

Entrevista con el Dr. Maurizio Taramasso

Dr Adolfo Ferrero Guadagnoli

Hospital Privado de Córdoba-Argentina Argentina , Córdoba

El Dr. Maurizio Taramasso forma parte del departamento de cardiología de la Universidad de Zürich. En esta oportunidad, el Dr. Adolfo Ferrero Guadagnoli (del Hospital Privado de Córdoba-Argentina) conversó con él acerca de lo que piensa de los estudios realizados, cuáles son sus espectativas acerca de los estudios que se vienen, cómo seleccionar pacientes, y qué recomendaría a los que están interesados en comenzar un programa de MitraClip®.

 

Dr. Adolfo Guerrero (AG): En función de los resultados del EVEREST II, ¿cuáles son los candidatos óptimos, en términos de perfil clínico y anatomía, para MitraClip en insuficiencia mitral degenerativa y qué casos deben excluirse del tratamiento?

 

Dr. Maurizio Taramasso (MT): El ensayo EVEREST II se llevó a cabo en una época anterior al surgimiento de la ecocardiografía 3D y antes de que se finalizara la curva de aprendizaje (de hecho, se dieron muchos desprendimientos simple de valvas), por lo que, hoy en día, los criterios clásicos del EVEREST se encuentran completamente desactualizados. Sin embargo, el candidato con insuficiencia mitral degenerativa ideal para MitraClip es un paciente con flail o prolapso mitral del segmento P2 aislado, sin dilatación relevante del anillo y con un riesgo quirúrgico elevado.

 

AG: En función de los resultados de COAPT y Mitra-FR, ¿cuáles son los criterios ecocardiográficos clave para la selección de pacientes con insuficiencia mitral funcional? ¿Qué casos deben excluirse del tratamiento?

 

MT: Los pacientes con patologías muy avanzadas en el ventrículo izquierdo posiblemente no se beneficien con MitraClip, en especial si la insuficiencia mitral no es tanta (área del orificio regurgitante efectivo menor que 0,3) en relación con la disfunción del ventrículo izquierdo. Los 2 ensayos mencionados también señalaron la importancia del desempeño técnico y la reducción de la insuficiencia mitral para obtener un beneficio en términos de pronóstico, lo que indica que el procedimiento debe ser realizado por operadores de mucha experiencia y en centros de alto volumen.

 

AG: En relación con la respuesta anterior, en la actualidad ¿MitraClip debería ser parte del tratamiento estándar para pacientes con insuficiencia cardiaca e insuficiencia mitral funcional aguda que cumplan los criterios de COAPT?

 

MT: Sí, definitivamente. No incluirlo sería antiético.

 

AG: En la disputa entre el tratamiento médico óptimo y MitraClip existe un tercer estudio que contribuirá en términos de evidencia. ¿Qué espera de RESHAPE-HF 2? ¿Sus resultados serán más cercanos a Mitra-FR o a COAPT?

 

MT: Espero con ansias sus resultados. Creo que no surgirá ninguna contradicción entre los estudios.

 

AG: Ni COAPT ni MITRA-FR incluyeron un grupo quirúrgico, pero el ensayo aleatorizado MATTERHORN se encuentra en curso, con lo que se resolverá la duda de si MitraClip es preferible en pacientes con insuficiencia mitral funcional. ¿Qué piensa de su resultado?

 

MT: En mi opinión, en casos de insuficiencia mitral funcional aislada, la cirugía tendrá un papel muy limitado en el futuro próximo, especialmente con el avance de los tratamientos de implante mitral por catéter para pacientes que no son buenos candidatos para la reparación por catéter.

 

AG: ¿Cree que, en casos en los que no hay necesidad de cirugía concomitante, la cirugía cardiaca tiene un papel que desempeñar en pacientes con insuficiencia mitral funcional?

 

MT: Nuevamente, su papel es muy limitado.

 

AG: ¿Qué recomendaciones haría que sirvan como pautas generales para comenzar un programa exitoso con MitraClip, en términos de selección de pacientes antes de lograr la curva de aprendizaje?

 

MT: La reproducibilidad es la clave del éxito. Esto solo puede lograrlo un equipo dedicado con amplia experiencia en el tratamiento de válvulas auriculo-ventriculares. No debería aceptarse ningún tipo de improvisación en la práctica.

 

AG: Finalmente, en relación con el concepto de un equipo completo (‘heart team’) tanto para la selección de pacientes como para la ejecución del estudio, ¿quién debería formar parte de tal equipo local, desde el punto de vista de las capacidades técnicas y la experiencia?

 

MT: Cirujanos y cardiólogos intervencionistas con experiencia en el diagnóstico y el tratamiento de las patologías de la válvula mitral, comprometidos con el tema. Un especialista en diagnóstico por imágenes intervencionista dedicado (para obtener los requisitos relacionados, consulte el artículo de Hahn et al. en JACC Cardiovascular Imaging): se trata de una nueva subespecialidad con competencias y habilidades específicas. Un especialista en insuficiencia cardiaca y un anestesiólogo, especialmente para los casos más complicados y para el seguimiento.

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