Resposta do Caso Clínico - IM grave pós-valvotomia percutânea

   O mecanismo da insuficiência valva mitral pós valvotomia é um dos critérios mais importantes a ser levado em conta para o manejo desta comlicação. O desenvolvimento de IM não necessariamente implica em falha do procedimento ou mesmo pior porgnóstico. A história natural destes pacientes é bastante variável, e uma parcela significativa destes pode tolerar essa condição sem necessariamente seguir para troca valvar.

   O ecocardiograma tem papel fundamental nesta decisão através da análise do mecanismo da IM e aspectos hemodinâmicos, tais como o gradiente médio imediatamente após a valvotomia, que apresenta importante informação prognóstica nestes pacientes.

Recomendo a leitura deste artigo.

Long-Term Outcomes of Significant Mitral Regurgitation After Percutaneous Mitral Valvuloplasty

Mi-Jeong Kim, MD; Jae-Kwan Song, MD; Jong-Min Song, MD; Duk-Hyun Kang, MD;

Young-Hak Kim, MD; Cheol Whan Lee, MD; Myeong-Ki Hong, MD; Jae-Joong Kim, MD;

Seong-Wook Park, MD; Seung-Jung Park, MD

Background—Mild commissural mitral regurgitation (MR) is associated with significantly higher restenosis-free survival after percutaneous mitral valvuloplasty (PMV), which suggests that different mechanisms of significant MR after PMV may have different clinical courses. We therefore analyzed long-term prognostic factors of significant MR after PMV.

Methods and Results—Echocardiographic and clinical follow-up data on 380 patients were analyzed (286 women, mean age 44 11 years) who underwent PMV with the Inoue balloon technique between 1995 and 2000. Significant MR developed in 47 patients (12.4%). The survival rate at 8 years was 96 3% and 98 10% in patients with and without significant MR, respectively (P 0.084). The most frequent mechanism was commissural MR, or MR that originated at the site of successful commissurotomy, which occurred in 27 of 47 patients (57%), whereas noncommissural MR occurred in 20 (43%) patients, 12 (26%) with subvalvular damage resulting in chordae rupture and flail motion and 8 (17%) with leaflet laceration. The 8-year event-free survival rate was significantly lower in patients with significant MR than in those without (47 8% versus 83 3%, P 0.001) and was significantly higher in patients with commissural versus noncommissural MR (63 11% versus 29 11%, P 0.001). Of the 47 patients with significant MR, who were followed up for 74 29 months, 19 patients (40%) underwent mitral valve replacement, and 28 patients (60%) received medical treatment only. Patients with commissural MR had a significantly lower rate of mitral valve replacement than patients with noncommissural MR (15% versus 70%, P 0.001). Multivariate analysis showed that atrial fibrillation (odds ratio, 7.4; 95% CI, 1.1 to 56.4; P 0.038), mean mitral gradient immediately after PMV (odds ratio, 1.5; 95% CI, 1.1 to 2.0; P 0.009), and the mechanism of MR (odds ratio, 16.7; 95% CI, 2.3 to 122.2; P 0.005) were independent factors associated with mitral valve replacement.

Conclusions—Clinical outcome of patients with significant MR after PMV varied according to MR mechanism and the adequacy of hemodynamic improvement, which is easily assessed by echocardiography immediately after PMV. (Circulation. 2006;114:2815-2822.)

Vejamos alguns gráficos que ilustram alguns pontos importantes referentes a esta complicação:

Média da área valvar em pctes com IM e sem IM após valvotomia percutânea

Sobrevida livre de eventos em pacientes com IM significativa ou não 

 Agora, observe quando é levado em conta a causa da IM, a sobrevida livre de eventos daqueles pacientes que desenvolvem IM comissural se aproxima daqueles pacientes que não apresentaram IM significativa. Isto pode sugerir que o contínuo processo de fibrose e calcificação da valva pode levar a "cura" desta IM...

Resumindo, nem tudo que reluz é OURO!!!