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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
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
SUPERVIVENCIA ACTUARIAL
(Ann Thorac Surg 2007;84:871–9)
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
SUPERVIVENCIA
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
COMPLICACIONES: REINTERVENCION
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
COMPLICACIONES: REINTERVENCION
late reoperations 5—10% (4.5% in our experience with a mean follow-up of 5.8 years).
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
REINTERVENCIONES
9 INTERVENCIONES CORONARIAS
4 CAMBIO VALVULAR AORTICO
2 OBSTRUCCION TRACTO SALIDA VI
6 TRACTO DE SALIDAD DEL VENTRICULO DERECHO
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
• 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
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
¿ FRECUENCIA?
¿CÓMO DIAGNOSTICAR ?
¿CUÁNDO HACER EL ESTUDIO ?
¿CUÁNDO Y COMO TRATAR?
LESIONES CORONARIAS
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
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 H.G.U.GREGORIO MARAÑON
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
LESIONES CORONARIAS H.G.U.GREGORIO MARAÑON
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
LESIONES CORONARIAS
ETIOLOGIA
FIBROSIS DEL OSTIUM POR LA SUTURA
ENGROSAMIENTO INTIMA
ACODAMIENTO, COMPRESION CON EL CRECIMIENTO
REACCION INFLAMATORIA A LA MANIPULACION QUIRURGICA
H.G.U.GREGORIO MARAÑON
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
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
H.G.U.GREGORIO MARAÑON
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
LESIONES CORONARIAS H.G.U.GREGORIO MARAÑON
LESIONES CORONARIAS H.G.U.GREGORIO MARAÑON
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
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
H.G.U.GREGORIO MARAÑON
(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)
Coronarias; DIAGNOSTICO H.G.U.GREGORIO MARAÑON
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
Coronarias; DIAGNOSTICO H.G.U.GREGORIO MARAÑON
Coronarias; DIAGNOSTICO H.G.U.GREGORIO MARAÑON
Coronarias; DIAGNOSTICO H.G.U.GREGORIO MARAÑON
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
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.
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
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
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
Lesiones coronarias: PROTOCOLO
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
H.G.U.GREGORIO MARAÑON
Lesiones coronarias: PROTOCOLO
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.
H.G.U.GREGORIO MARAÑON
Lesiones coronarias: PROTOCOLO
Angeli E et al. Eur J Cardiothorac Surg 2010;38:714-720
H.G.U.GREGORIO MARAÑON
Lesiones coronarias: PROTOCOLO
H.G.U.GREGORIO MARAÑON
Lesiones coronarias: PROTOCOLO
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
Lesiones coronarias: TRATAMIENTO H.G.U.GREGORIO MARAÑON
Lesiones coronarias: TRATAMIENTO H.G.U.GREGORIO MARAÑON
J Thorac Cardiovasc Surg 2010;139:349-353
less than 3 years of age
8/18
Lesiones coronarias: TRATAMIENTO H.G.U.GREGORIO MARAÑON
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
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
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
LESIONES CORONARIAS
CLINICA-DIAGNOSTICO
FRECUENTEMENTE ASINTOMATICOS
ECG,ECO P.ESFUERZO Y SPET NO VALORABLES
CORONARIOGRAFIA
TAC
RNM ?¿
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
LESIONES CORONARIAS
MANEJO
NINGÚN CONSENSO
3 AÑOS
5 AÑOS
CADA 5 AÑOS
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
LESIONES CORONARIAS
TRATAMIENTO
ASINTOMATICOS: MEDICO O NADA
SINTOMATICOS: CIRUGÍA, ANGIOPLASTIA STENT
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
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
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
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
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
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
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H.G.U.GREGORIO MARAÑON XVIII CURSO DE CARIOLOGÍA INFANTIL MADRID 2012
H.G.U.GREGORIO MARAÑON
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