Tratamento cirúrgico de pacientes com insuficiência cardíaca: revascularização miocárdica, reconstrução ventricular, cirurgia valvar mitral

Abstract

Heart failure, a final outcome of different cardiomyopathies is currently the most serious problem in the field of cardiology and public health.Despite the extraordinary progress made over the last two decades regarding the understanding of the deeper mechanisms of ventricular failure as an endocrine-metabolic syndrome, it is the major cause of death in the adult population.This justifies the use of polypharmacy with five or more active principles with a view to neutralizing different stages of the adrenergic stimulation cascade.The clinical application of these active principles fascinates professionals, leading them to attach great importance to the heart failure syndrome, so much so that they sometimes accept the etiology of the disease without further questioning and, beyond that, fail to identify causes of heart failure that could be removed.The identification of the causal mechanism of the disease and its removal or neutralization translates into a significant impact on the progression of the disease. This is the case of ischemic myocardiopathies, tachymyopathies, deposit and metabolic diseases and others.With the emergence of important and recent concepts on ventricular dynamics under the light of the double helix helicoidal mechanism and the acknowledgement of the harmful effects of ventricular sphericity, it is necessary to approach heart failure from a mechanicist point of view that is not opposed to the endocrine-metabolic concepts, but allows the expectation of a better management of this syndrome.Among the possibilities of surgical intervention in these situations, we will briefly discuss the revascularization of ischemic myocardium, ventricular reconstruction and the repair of secondary mitral insufficiency. Myocardial revascularizationMyocardial ischemic dysfunction can be reversed by surgical treatment, in sharp contrast with clinical management alone, as demonstrated by several studies; it constitutes a major criterion for surgery indication 1-5 .More recently, the Ephesus and Valiant studies, with cutoff values for ejection fraction between 0.35 and 0.40 have proved the advantages of surgical revascularization over clinical management in the medium to long term.It is worthy of notice that with the assessment of ischemia using scintigraphy, stress-echo test and more recently nuclear magnetic resonance imaging, the results are predictable to a high degree, whereas the statement of absence of ischemia, even if a pet scan is conducted, is subject to an error risk of approximately 20%.It is therefore difficult to deny the indication of revascularization in patients with poor ventricular performance when there are approachable distal coronary beds.There are doubts as to the benefit of revascularization when ventricular volumes are increased, and the results are not as satisfactory as revascularization in patients without an enlarged left ventricle 6-8 .These observations constitute the basis for the proposal of associating some type of ventricular reconstruction with myocardial revascularization, and...