Fisiopatología de la conducción cardíaca en pacientes con estenosis aórtica severa tratados con prótesis aórtica corevalve. Análisis de predictores de necesidad de marcapasos

• Autores: J. López Aguilera
• Directores de la Tesis: José Suárez de Lezo Cruz-Conde (dir. tes.), José Segura (codir. tes.)
• Lectura: En la Universidad de Córdoba (ESP) ( España ) en 2015
• Idioma: español
• Tribunal Calificador de la Tesis: Alfonso Medina Fernández-Aceytuno (presid.), Miguel Ángel Romero Moreno (secret.), Eduardo de Teresa Galván (voc.)
• Materias:
  • Ciencias médicas
    • Medicina interna
      • Cardiología
• Enlaces
  • Tesis en acceso abierto en: Helvia
• Resumen

  • RESUMEN DE LA TESIS DOCTORAL DE D./Dª JOSÉ LÓPEZ AGUILERA FISIOPATOLOGÍA DE LA CONDUCCIÓN CARDIACA EN PACIENTES CON ESTENOSIS AÓRTICA SEVERA TRATADOS CON PRÓTESIS AÓRTICA COREVALVE. ANÁLISIS DE PREDICTORES DE NECESIDAD DE MARCAPASOS.

    1. Introducción y motivación de la tesis.

    La implantación de prótesis aórticas CoreValve por vía percutánea se ha establecido como un tratamiento viable para los pacientes de avanzada edad con estenosis aórtica severa sintomática y elevado riesgo quirúrgico. Con frecuencia se producen trastornos severos de la conducción cardiaca tras la implantación de la prótesis, unas veces provisionales, en otras ocasiones definitivos. Un porcentaje no despreciable de los mismos acaban requiriendo la implantación de un marcapasos definitivo. Entre dichos trastornos, los más frecuentemente objetivados han sido: el bloqueo completo de la rama izquierda del haz de His, y el bloqueo auriculoventricular de tercer grado.

    Existen numerosos trabajos que aportan datos acerca de factores predictores de la necesidad de marcapasos, y en este momento, existe información contradictoria acerca de la evolución a medio y largo plazo de los pacientes que precisan estimulación cardiaca permanente o que quedan con bloqueo de rama izquierda definitivo tras el implante valvular percutáneo.

    El objetivo principal del estudio es analizar la incidencia de necesidad de marcapasos en una serie de 190 pacientes con estenosis aórtica severa tratados de forma consegutiva con la prótesis Corevalve en el Hospital Universitario Reina Sofía.

    Los objetivos secundarios que se han definido son:

    1. Analizar las características de las alteraciones de la conducción que se producen tras el implante valvular. 2. Evaluar los cambios que se producen en la conducción auriculoventricular mediante el análisis de los intervalos AH y HV en los electrogramas intracavitarios registrados antes y tras el implante de la prótesis percutánea.

    3. Establecer las indicaciones de estimulación cardiaca permanente tras el implante de la prótesis Corevalve.

    4. Identificar los factores clínicos, angiográficos, electrocardiográficos de superficie e intracavitarios que predicen la necesidad de un marcapasos definitivo.

    5. Evaluar la evolución clínica de los pacientes que presentaron alteraciones electrocardiográficas durante el implante de prótesis aórtica Corevalve.

    2. Contenido de la investigación Desde abril-08 a diciembre-13 se seleccionaron 190 pacientes con estenosis aórtica severa sintomática tratados con este tipo de prótesis. Se analizaron características clínicas, electrocardiográficas, electrofisiológicas, hemodinámicas y de imagen para predecir la necesidad de marcapasos.

    La edad media fue 78 ± 5 años y el EuroSCORE logístico, 17.2 ± 12%. Tras el implante se produjo un 49 % de bloqueo de rama izquierda de novo (89 pacientes) y 46 pacientes (25%) precisaron de marcapasos definitivo, bien inmediatamente tras el implante (33 pacientes) o en la evolución (13 pacientes). El PR se alargó de 173 ± 47 mseg a 190 ± 52 mseg (p<0,01), el intervalo AH pasó de 95 ± 39 mseg a 108 ± 41 mseg (p<0,01), respectivamente. De forma similar el QRS se incrementó de 98 ± 22 mseg a 129 ± 24 mseg (p<0,01), y el HV se alargó de 54 ± 10 mseg a 66 ± 23 mseg (p<0,01). La necesidad de marcapasos se relacionó de forma independiente con la presencia de un bloqueo de rama derecha basal y la profundidad de la prótesis en el ventrículo izquierdo.

    Se realizó seguimiento de los pacientes que quedaron con alteraciones de la conducción cardiaca: Los pacientes con bloqueo de rama izquierda de nueva aparición tras el implante de la válvula aórtica CoreValve no tuvieron más mortalidad que los pacientes que quedaron sin trastornos de la conducción tras el tratamiento percutáneo (44,9% vs. 48,1%, p = 0,732). Tampoco hubo mayor incidencia de necesidad de marcapasos (10,1% vs. 13,1%, p = 0,936) ni necesidad de ingresos por insuficiencia cardiaca (15,0% vs. 19,9%, p = 0,414) a los 60 meses de seguimiento.

    Los pacientes con necesidad de marcapasos permanente tras el implante de válvula aórtica CoreValve no tuvieron más mortalidad que los pacientes que no precisaron estimulación cardiaca permanente (42,3% vs. 45,5%, p = 0,157). Sí hubo mayor necesidad de ingresos por insuficiencia cardiaca a los 60 meses de seguimiento entre los pacientes que precisaron estimulación cardiaca permanente (8,9% vs. 46,7%, p = 0,023).

    3. Conclusiones:

    La necesidad de marcapasos definitivo tras el implante de una válvula aórtica percutánea CoreValve se produce hasta en una cuarta parte de los pacientes. En la mayoría de las ocasiones, la necesidad de estimulación cardiaca permanente acontece en las primeras 72 horas tras el implante protésico, si bien un porcentaje no despreciable puede acabar necesitando un marcapasos definitivo en la evolución.

    1. El implante de una prótesis aórtica Corevalve tiene una alta incidencia de alteraciones de la conducción tanto auriculoventricular como intraventricular. El trastorno de la conducción que se produce con más frecuencia es el bloqueo de rama izquierda, seguido del bloqueo auriculoventricular completo. Se produce un alargamiento significativo tanto del intervalo PR como del QRS tras el implante protésico.

    2. El implante de la prótesis aórtica Corevalve, además de producir una alteración de la conducción intraventricular por lesión del Haz de His y sus ramas, puede alterar la conducción auriculoventricular a nivel del nodo AV compacto, puesto de manifiesto tanto por un alargamiento significativo tanto del intervalo HV como del intervalo AH, respectivamente.

    3. El bloqueo auriculoventricular completo fue la indicación más frecuente de estimulación cardiaca permanente en la práctica totalidad de los pacientes sometidos al implante de una prótesis aórtica Corevalve.

    4. La necesidad de estimulación cardiaca permantente podría ser previsible en base a datos clínicos del paciente (varones, con antecedentes de síncope) y del electrocardiograma previo a la implantación (presencia de bloqueo de rama derecha basal). También debe intentarse un implante poco profundo del stent valvulado en el tracto de salida del ventrículo izquierdo.

    5. El bloqueo de rama izquierda inducido tras el implante de una prótesis aórtica Corevalve no tiene significado pronóstico a medio y largo plazo en la mortalidad de estos pacientes, si bien, la necesidad de estimulación cardiaca permanente podría producir una merma en la supervivencia y mayor morbilidad a medio plazo.

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