Dr. Enrique Maroto - Aymon · Área de ciencias cardiolÓgicas pediÁtricas h.g.u.gregorio maraÑon...

ÁREA DE CIENCIAS CARDIOLÓGICAS PEDIÁTRICAS H.G.U.GREGORIO MARAÑON

Dr. Enrique Maroto

MADRID 2012

www.cardiologiainfantilgm.net

H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012

ANTECEDENTES HISTORICOS

H.G.U.GREGORIO MARAÑON




SUPERVIVENCIA ACTUARIAL

(Ann Thorac Surg 2007;84:871–9)




SUPERVIVENCIA




COMPLICACIONES: REINTERVENCION




COMPLICACIONES: REINTERVENCION

late reoperations 5—10% (4.5% in our experience with a mean follow-up of 5.8 years).




REINTERVENCIONES

9 INTERVENCIONES CORONARIAS

4 CAMBIO VALVULAR AORTICO

2 OBSTRUCCION TRACTO SALIDA VI

6 TRACTO DE SALIDAD DEL VENTRICULO DERECHO




• ESTENOSIS ARTERIA PULMONAR Y SUS RAMAS

• OBSTRUCCION CORONARIA

• INSUFICENCIA DE LA VALVULA OARTICA

• DILATACION AORTA ASCENDENTE

• INSUFICIENCIA PULMONAR

• ESTENOSIS SUPRAVALVULAR AORTICA

• ARRITMIAS

COMPLICACIONES A LARGO PLAZO

ESPECTRO DE PROBLEMAS




¿ FRECUENCIA?

¿CÓMO DIAGNOSTICAR ?

¿CUÁNDO HACER EL ESTUDIO ?

¿CUÁNDO Y COMO TRATAR?

LESIONES CORONARIAS



LESIONES CORONARIAS H.G.U.GREGORIO MARAÑON

The incidence of late coronary stenosis requiring reintervention

is generally low ( 3%), and silent coronary obstructive lesions

have shown a prevalence of 7%

The main clinical manifestations of coronary obstruction

reported after an ASO are heart failure, arrhythmias, or sudden

death



LESIONES CORONARIAS

ETIOLOGIA

FIBROSIS DEL OSTIUM POR LA SUTURA

ENGROSAMIENTO INTIMA

ACODAMIENTO, COMPRESION CON EL CRECIMIENTO

REACCION INFLAMATORIA A LA MANIPULACION QUIRURGICA




LESIONES CORONARIAS

FACTORES DE RIESGO:

The influence of variations in coronary artery anatomy on risk

of future complications or premature death remains uncertain

Pasquali and colleagues reported that coronary artery

anatomic patterns with intramural origin or single-ostium

looping are at increased risk for mortality and morbidity.

Not find any predictors of late coronary lesions in our

study . S. Oda et al. / European Journal of Cardio-Thoracic

Surgery


Importantly, the investigators showed that classic noninvasive tests— electrocardiogram, echocardiography, treadmill test, myocardial scintigraphy—are not sensitive enough to detect significant coronary stenosis.

PRUEBAS DIAGNOSTICAS




Coronarias; DIAGNOSTICO

Selective coronary angiography is a proven tool used to detect these

lesions, but it poses greater risk to the patient because of its invasive

nature

Conversely, multislice computer tomography has been developed as a

noninvasive screening method that can be performed as effectively as

selective coronary angiography.

Recent research with noninvasive myocardial perfusion magnetic

resonance imaging has yielded promising results for the detection of

coronary stenosis in pediatric patients


(Ann Thorac Surg 2011;92:1747–55)

130 consecutive such children (mean age 5.6 1.1 years, weight 19.7 9 kg, follow-up 5.3 1 years) underwent 64-slice CT angiography in the 24 h before or after their conventional coronary study

Coronarias; DIAGNOSTICO H.G.U.GREGORIO MARAÑON

ANGIOGRAPHY has two important limitations in assessing children after ASO. First, the selectively engaged coronary catheter may straighten or pass through an ostial kink or stenosis, which might then be more difficult to visualize. In addition, the images of the coronary vessels are not seen in the topographic context of the adjacent great arteries, which is often the underlying reason for coronary lesions (because of stretching, compression, and/or kinking)


Interestingly, CT was also able to visualize the topographic relationship of the proximal vessels relative to the great arteries Additional findings on CT., showed mild coronary lesions (below the threshold of 30% diameter stenosis). In none of these cases had the lesions been identified in invasive angiography





Taylor Chung a,⁎, Rajesh Krishnamurthy b,c, Lorna Browne b,cb Edward B,

Houston, Texas 77030, USA c Baylor College of Medicine, USA

This low dose technique can allow for periodic follow

up examinations while adhering to the concept of ALARA.

MRA, though much more technically challenging with slightly inferior

spatial resolution, can be an alternative to coronary CTA especially

when the evaluation is mainly limited to the origin and proximal

course of the coronary arteries. With the continued evolution of CT

and MR techniques, there should be a progressive decline in the need

for invasive diagnostic imaging.




Lesiones coronarias: PROTOCOLO

CAG before they enter primary school and

junior high school.

We had performed CAG in 54.3% (n = 210) of

patients at 9.6 ± 5.1 years after

ASO and found the incidence of coronary lesions

5.7% (n = 12





Legendre et al. recommended CAG at 5, 10, 15 years after ASO

Perform selective coronary angiography and exercise

stress test at the school age for all children operated

with ASO and combined with SPET for those with

complicated early postoperative course.

Thus SPET at rest and under exercise, combined with

multislice CT may give better information

Chemical or exercise-induced stress echocardiography

has been used in children to evaluate the coronary

circulation and myocardial performance under stress

and described as a sensitive method



The age of the asymptomatic patients at

which control angiograms should be done

is unclear.

We believe it should be done before puberty when

perfoming of exercise ECG is achievable, the risks of

selective coronary angiography are small, and before

demanding physical activities might increase

significantly.



Angeli E et al. Eur J Cardiothorac Surg 2010;38:714-720



Therapeutic options for coronary ostial stenosis or

obstruction are patch ostioplasty, percutaneous

luminal dilatation, and stenting

Lesiones coronarias: TRATAMIENTO H.G.U.GREGORIO MARAÑON

However, the decision of endovascular stent

implantation in the coronary arteries during childhood

and adolescence can be questioned. The stent will

need redilatation when the patient is growing.

Stents have been reported to be effective with low

risk for intimal proliferation and restenosis



J Thorac Cardiovasc Surg 2010;139:349-353

less than 3 years of age

8/18




LESIONES CORONARIAS

EPIDEMIOLOGIA

NO SE SABE

NO ESTUDIOS PROSPECTIVOS

ACTUALMENTE: 7-11%

Estudiados < 50%

Asintomáticos >50%

DOS PICOS A LOS 10-15 AÑOS

FRECUENTE A LOS 5 AÑOS

NO FACTORES DE RIESGO CLAROS (CORONARIAS)

BAJA MORTALIDAD

INCIDENCIA SERÁ MAS ELEVADADA




LESIONES CORONARIAS

CLINICA-DIAGNOSTICO

FRECUENTEMENTE ASINTOMATICOS

ECG,ECO P.ESFUERZO Y SPET NO VALORABLES

CORONARIOGRAFIA

TAC

RNM ?¿




LESIONES CORONARIAS

MANEJO

NINGÚN CONSENSO

3 AÑOS

5 AÑOS

CADA 5 AÑOS




LESIONES CORONARIAS

TRATAMIENTO

ASINTOMATICOS: MEDICO O NADA

SINTOMATICOS: CIRUGÍA, ANGIOPLASTIA STENT




LESIONES CORONARIAS

PROPUESTA:

1-5 AÑOS: ECG / ECO: EXCEPCIONAL MORTALIDAD

5 AÑOS:

RNM (frecuencia cardiaca) . Visualización ostium coronario

TAC técnicamente no definición de la RNM

Anual ECG, ECO, P. Esfuerzo. No SPET




LESIONES CORONARIAS

PROPUESTA:

10 AÑOS:

RNM

Anual ECG, ECO, P. Esfuerzo. No SPET

(+) o no definición: TAC

TAC (+): coronariografia-cirugía

15 AÑOS = Igual

20 AÑOS= igual




LESIONES CORONARIAS

PROPUESTA:

SI ASINTOMATICO E IMAGEN PATOLOGICA:

LESION TRONCO > 50%

LESION RAMAS> 75%

SI MAYOR DE 10 AÑOS:

Circulación colateral importante

TRATAMIENTO INVASIVO

SI MENOR 10 AÑOS:

Tratamiento medico y seguimiento




LESIONES CORONARIAS

PROPUESTA:

SI SINTOMATICO E IMAGEN PATOLOGICA:

CARDIOLOGÍA INTERVENCIONISTA / CIRUGÍA

EXPERIENCIA DEL CENTRO

RESULTADOS NUEVAS SERIES

ÁREA DE CIENCIAS CARDIOLÓGICAS PEDIÁTRICAS H.G.U.GREGORIO MARAÑON

MADRID 2012

MUCHAS GRACIAS

Dr. Enrique Maroto - Aymon · Área de ciencias cardiolÓgicas pediÁtricas h.g.u.gregorio maraÑon...

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