congenital heart disease: pda and aorta coarctation
TRANSCRIPT
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CIRUGÍA CARDIOVASCULAR
PERSISTENCIA DE CONDUCTO ARTERIOSO
COARTACIÓN DE LA AORTA
R. Martínez P. pre-preMIPHospital Regional de Puerto Vallarta
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CONTENIDO• Generalidades de circulación fetal
• Cambios circulatorios posnatales
• Generalidades de la nomenclatura de las cardiopatías
• Generalidades clínicas del paciente cardiópata: PDA y coartación
• Técnicas de abordaje quirúrgico de PDA y coartación
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CIRCULACIÓN FETAL
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CAMBIOS POSNATALES• Separación de
circulaciones pulmonar y sistémica
o Cierre de ducto arterioso
o Cierre de foramen ovale
• Aumentar flujo pulmonar
• El bombeo izquierdo se quintuplica
• Cierre del ducto venoso
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CARDIOPATIAS CONGENITAS
• Malformaciones cardiacas o de sus grandes vasos presentes al nacimiento y que se originan en las primeras semanas de gestación por factores que actúan alterando o deteniendo el desarrollo embriológico del sistema cardiovascular.
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CARDIOPATIAS CONGENITAS DE
MAYOR FRECUENCIA
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NOMENCLATURA• Aspecto clínicooCianógenos
oNo cianógenos
• Aspecto quirúrgicooVan Praagh
oAnderson*
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NOMENCLATURA CLÍNICA
NO CIANOGENAS• Defecto septal ventricular• Defecto septal atrial• PDA• Coartación de la aorta• Estenosis aortica congénita• Defecto septal AV• Ventana aortopulmonar• Arco aórtico interrumpido• Estenosis mitral
CIANOGENAS• Tetralogía de Fallot• Estenosis pulmonar• Transposición de grandes art.• Atresia pulmonar• Atresia tricúspide• Tronco arterioso• Sx de hipoplasia izquierda
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NOMENCLATURA QX• Basado en la morfología observada
• Aplicable a todas las malformaciones congénitas (conocidas y no conocidas)
• Claro y conciso, no ambigua
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NOMENCLATURA
• Analiza por separado los tres segmentos morfológicamente: atrios, masa ventricular y segmento arterial
• Después analiza las uniones de los segmentos• Rentable para el cirujano, no desvaría en teoría embriológica
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NOMENCLATURA: MÉTODO DE ANDERSON
• Disposición atrial
• Conexiones atrioventriculares
• Conexiones ventriculoarteriales
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DISPOSICION ATRIAL
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CONEXIONES ATRIOVENTRICULARES
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CONEXIONES VENTRICULOARTERIAL
ES
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POSICION CÁRDIACA
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SITUS SOLITUSDISCORDANCIA AVDISCORDANCIA VA
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PERSISTENCIA DEL CONDUCTO ARTERIOSO
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CONDUCTO ARTERIOSO
• Conecta tronco pulmonar con aorta descendente
• Distal al origen de subclavia izquierda
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CIERRE DEL C. ARTERIOSO
La contracción de su túnica media es la que
lo cierra al nacimiento
Cierre entre semana 2-3 posnatal 80% de prematuros <1200 kg 45% de prematuros <1750 kg
<<PDA>>
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CLÍNICA• Hiperactividad precordial
• Pulsos amplios en las cuatro extremidades
• Soplo sistólico o continuo en segundo (¿tercero, cuarto?) EIC izquierdo
• Deterioro ventilatorio
• Edema pulmonar (dato no constante)
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DIAGNÓSTICO• Muchos niños son asintomáticos
• ¿Soplo sistólico?
• Pulsos periféricos aumentados
• Murmullo en segundo y tercer espacio intercostal (crescendo-decrescendo)
• ¿Cardiomegalia?
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DIAGNÓSTICO• Eco cardiografía Doppler o eco cardiografía bidimensional
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Diuresis <0.6 ml/kg/hra Urea >40 mg/dL Creatinina >1.8 mg/dL Enterocolitis necrosante Plaquetas < 60 000 m3
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INDICACIONES DEL PROCEDIMIENTO
QUIRÚRGICO
• Insuficiencia cardiaca congestiva que no responde a tratamiento
• Si no hay cierre con el empleo de indometacina o ibuprofeno →sintomáticos
• Todos deberían cerrarse por el riesgo de endocarditis bacteriana subaguda
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PROCEDIMIENTO QUIRURGICO
• LIGADURA
• DIVISIÓN (CORTE)
• PERCUTANEA CON DISPOSITIVOS (AMPLATZER™)
• LIGACLIP
• CIERRE DESDE EL INTERIOR DE LA ARTERIA PULMONAR
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LIGADURA
TORACOTOMIA 4to EIC POSTEROLATERAL
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LIG
AD
URA
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LIGADURA
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DIVISION
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CIERRE PERCUTANEO (AMPLATZER™)• Puede cerrar hasta PDA• con este dispositivo en particular cierrede hasta 14 mm diametro
• Indicados en paciente >6 kg de peso
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LIGACLIP
Infantes prematuros
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CIERRE DESDE EL INTERIOR DE LA
ARTERIA PULMONAR
Situaciones como calcificación de PDAAdhesiones intrapericardicas
Requiere hipotermia (28°C nasofaringe)
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COARTACION DE LA AORTA
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COARTACIÓN: DEFINICION
• Estrechamiento congénitode la aorta
• Usualmente se sitúa entre elorigen de la subclaviaizquierda proximalmente yla unión de la aorta y elducto arterioso distalmente
1
2
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¿CLASIFICACIÓN? ¿UTILIDAD?
POR SUS DIFERENTES FORMAS DE PRESENTACION DE ACUERDO A LA EDAD…
• Bonnett (1903)o Infantil
o Adulta “SINTOMATICOS Y ASINTOMATICOS”
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CLÍNICA: SINTOMÁTICOS
• Insuficiencia cardiaca congestiva
• Pulsos radiales palpables y prominentes
• Pulsos femorales débiles o ausentes
• Lesiones cardiacas asociadas (75% ; clínica propia: hallazgos propios…)
“INFANTES”
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RADIOGRAFÍA DE TORAX:
SINTOMATICOS• Ensanchamiento mediastinal (¿cardiomegalia?)
• Congestión en campos pulmonares
• Reforzamiento de patrón vascular / incremento de vascularidad
• Edema pulmonar franco
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DIAGNOSTICO• Se establece con ecocardiografia 2D y
doppler
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CLÍNICA: ASINTOMÁTICOS
• Raramente produce síntomas• Hallazgo en exploración de rutina
o Pulsos femorales débiles o ausentes
o Murmullo cardiaco
o Hipertensión en extremidades superiores
o ¿cardiomegalia?
o ECG normal o hipertrofia ventricular izquierda
o Ecocardiograma no será tan útil para valoración
o ANGIOCARDIOGRAFIA O MRI
SE RECOMIENDA TRATAMIENTO QUIRURGICO APENAS SE DIAGNOSTIQUE
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PROCEDIMIENTO QUIRURGICO
• ACCESO TORACOTOMIA LATERAL 3er a 4to EIC izquierdo
• Retracción de pulmón de manera anterior
• Resección y anastomosiso Preferida antes que otra técnica
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RESECCIÓN Y ANASTOMOSIS
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RESECCIÓN Y ANASTOMOSIS
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RESECCIÓN Y ANASTOMOSIS
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COMPLICACIONES• PARAPLEGIA• 0.14% raro• PrecaucionesoClampeo el menor tiempo posible (<20
min)oEvitar acidosisoHipotermia moderada (superficial)oLavado pleural con solución salina fría
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…GRACIAS
De corazón….