Artículo de Revision

Reparación Mitral Percutánea con MitraClip en Pacientes con Insuficiencia Mitral Funcional: Análisis de los estudios MITRA-FR y COAPT

Dr. Xavier Freixa

Instituto Cardiovascular Clinic, Hospital Clinic de Barcelona, España España , Barcelona

Reparación Mitral Percutánea con MitraClip™ en Pacientes con Insuficiencia Mitral Funcional: Análisis de los resultados aparentemente contradictorios de los estudios MITRA-FR y COAPT.

En medicina, pocas veces se da la circunstancia de disponer de dos artículos publicados en el mismo período de tiempo con resultados aparentemente contradictorios entre sí. Este hecho aconteció entre Agosto y Setiembre de 2018 con los estudios MITRA-FR 1 y COAPT 2. Ambos estudios evaluaban a pacientes con insuficiencia mitral funcional severa y comparaban el tratamiento médico óptimo con o sin reparación mitral percutánea con el sistema MitraClip™. El estudio MITRA-FR se presentó en el ESC de Munich en Agosto de 2018 y provocó cierta decepción al no demostrar diferencias en cuanto a reingresos por insuficiencia cardíaca o mortalidad a los 12 meses entre grupos. Este estado de decepción y, en cierta manera, incredulidad, tan solo duró 2 meses. A finales de Setiembre de 2018, el Professor Greg Stone presentó los resultados del estudio COAPT en el TCT de San Diego. Los resultados de este estudio demostraron una reducción de los ingresos por insuficiencia cardíaca y mortalidad en pacientes con insuficiencia mitral funcional a los 24 meses.

 

Ambos estudios fueron publicados en la prestigiosa revista New England Journal of Medicine, pero, ¿cuáles son las claves que permiten entender las diferencias entre los estudios?. En la tabla 1 se pueden observar las principales diferencias entre ambos. En resumen, los pacientes tratados en COAPT tenían una menor dilatación del ventrículo izquierdo y un mayor grado de insuficiencia mitral (ERO). En otras palabras, eran pacientes menos evolucionados y en los que la insuficiencia mitral jugaba un papel más importante en los síntomas. Además de reclutar al doble de pacientes (304 en MITRA-FR vs. 614 en COAPT), los resultados técnicos del procedimiento, también fueron mejores en la población COAPT al tener un menor porcentaje de insuficiencia mitral severa post-clip y una menor tasa de complicaciones del procedimiento.

 

Finalmente, otras de las claves para explicar los resultados son las diferencias en el seguimiento de los pacientes. Mientras que en MITRA-FR el seguimiento era de 12 meses, en COAPT fue de 24 meses, resaltando los beneficios de la terapia más a largo plazo. En conclusión, las lecciones que nos dejan MITRA-FR y COAPT es que la terapia con MitraClip™ en pacientes con insuficiencia mitral funcional aporta mayor beneficio en fases tempranas de dilatación ventricular y en pacientes con insuficiencias mitrales más severas.

 

TABLA 1

null

FEVI: fracción de eyección ventrículo izquierdo; VTDVI: volumen telediastólico ventrículo izquierdo; ERO: orificio regurgitante; IM: insuficiencia mitral.
* Dispositivo no implantado, complicaciones vasculares que requieran cirugía, shock cardiogénico, ictus, taponamiento cardiaco y cirugía cardiaca urgente.

 

Referencias Bibliográficas

1. Obadia JF, Messika-Zeitoun D, Leurent G, Iung B, Bonnet G, Piriou N, et al. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation. The New England journal of medicine. 2018;379(24):2297-306.

2. Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim DS, Mishell JM, et al. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. The New England journal of medicine. 2018;379(24):2307-18.

 
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