Transplante de valva mitral heteróloga: Nova alternativa cirúrgica: estudo clínico inicial

Vrandecic, Mário O; Gontijo Filho, Bayard; Fantini, Fernando Antônio; Silva, João Alfredo de Paula e; Barbosa, Juscelino Teixeira; Gutierrez, Cristiana; Barbosa, Maurício R; Oliveira, Sérgio Almeida de; Morea, Mário

doi:10.1590/S0102-76381993000200002

Resumos

A substituição da valva mitral tem sido realizada, nestes 30 anos, usando-se o modelo aórtico. Embora o resultado clínico, na maioria dos pacientes seja satisfatório, existem, restrições específicas, tanto entre as biopróteses, como nas próteses mecânicas. A experiência no tratamento dos tecidos biológicos, assim como a fabricação de substitutos valvares, há 2 décadas, tem permitido o desenvolvimento da valva mitral heteróloga. Este substituto mitral foi implantado em 38 pacientes, com a preservação da função ventricular. A idade média foi de 29 anos, predominando o sexo feminino (69%), e a etiologia reumática em 86%. A dupla lesão foi a mais freqüente (53%). A classificação funcional deste grupo engloba (47%) em classe II e (53%) em classe IV da NYHA. A técnica cirúrgica é reproduzível e proporcionou resultados clínicos satisfatórios durante 12 meses de evolução, demonstrando que a valva mitral heteróloga é o substituto natural, quando indicada a troca valvar. Houve uma reoperação em paciente que apresentou insuficiência mitral moderada, devido à desproporção entre a valva escolhida e o anel mitral bastante dilatado. Os resultados clínico, hematológico e ecocardiográfico têm sido extremamente gratificantes, durante o período de seguimento. O desenho mitral natural, aliado ao tratamento anticalcificante, é o que deve proporcionar melhor qualidade de vida e a durabilidade desejada.

valva mitral; valvas cardíacas

Mitral valve replacement has been performed for the last 30 years using an aortic designed valve, to fulfil specific requirements of the left ventricle. The clinical results obtained by such devices have been generally favorable, although specific restrictions are obvious because of their design. The knowledge and experience acquired by Biocor Laboratories in the last two decades, in production of biological heart valve substitutes, contributed positively to the research, development and manufacture of the heterologous mitral valve substitute. This stentless heterologous mitral valve was implanted in 38 patients, without hospital mortality. Their mean age was 29 years. Female gender predominated (69%). The most common mitral dysfunction was the double mitral valve lesion (53%). Eighteen (47%) patients were in functional class III and 20 (53%) in class IV of the NYHA. There was one valve related complication (our first patient), due to disproportion of patients, large annulus and the incorrectly size chosen. This complication led us to the strict adherence of our protocol, which is based upon animal experimentation. The satisfactory operatory and clinical results, throughout this 12 months of follow-up, confirm that the stentless heterologous mitral valve is the natural mitral substitute, when considering mitral valve replacement. This first natural mitral valve substitute, tanned with a non-aldehyde tissue treatment, proved to avoid calcification and to produce no foreign reaction, hence it may be the best choice in order to obtain better quality of life and the desired valve durability. Using both, the natural design mitral valve and the non-aldehyde treatment, the last 6 patients of this series received this devicxe and is certainly hoped that, due to the more natural model and the non-calcificant and inhert tissue, patients own cells will be responsible to greatly delay tissue degeneration, providing longterm durability.

heart valves, mitral; heart valves

ARTIGOS ORIGINAIS

Transplante de valva mitral heteróloga. Nova alternativa cirúrgica: estudo clínico inicial

Heterologous mitral valve transplant. New surgical technique: initial clinical trial

Mário O. Vrandecic^I; Bayard Gontijo Filho^I; Fernando Antônio Fantini^I; João Alfredo de Paula e Silva; Juscelino Teixeira Barbosa^I; Cristiana Gutierrez^I; Maurício R. Barbosa^I; Sérgio Almeida de Oliveira^II; Mário Morea^III

^IDo Instituto Biocór

^IIDo Hospital da Beneficência Portuguesa. São Paulo, SP

^IIIDa Universidade de Torino. Itália

^{Endereço para separatas} Endereço para separatas: Mário Vrandecic Caixa Postal 106. 30161-970 Belo Horizonte, MG, Brasil

RESUMO

A substituição da valva mitral tem sido realizada, nestes 30 anos, usando-se o modelo aórtico. Embora o resultado clínico, na maioria dos pacientes seja satisfatório, existem, restrições específicas, tanto entre as biopróteses, como nas próteses mecânicas. A experiência no tratamento dos tecidos biológicos, assim como a fabricação de substitutos valvares, há 2 décadas, tem permitido o desenvolvimento da valva mitral heteróloga. Este substituto mitral foi implantado em 38 pacientes, com a preservação da função ventricular. A idade média foi de 29 anos, predominando o sexo feminino (69%), e a etiologia reumática em 86%. A dupla lesão foi a mais freqüente (53%). A classificação funcional deste grupo engloba (47%) em classe II e (53%) em classe IV da NYHA. A técnica cirúrgica é reproduzível e proporcionou resultados clínicos satisfatórios durante 12 meses de evolução, demonstrando que a valva mitral heteróloga é o substituto natural, quando indicada a troca valvar. Houve uma reoperação em paciente que apresentou insuficiência mitral moderada, devido à desproporção entre a valva escolhida e o anel mitral bastante dilatado. Os resultados clínico, hematológico e ecocardiográfico têm sido extremamente gratificantes, durante o período de seguimento. O desenho mitral natural, aliado ao tratamento anticalcificante, é o que deve proporcionar melhor qualidade de vida e a durabilidade desejada.

Descritores: valva mitral, cirurgia; valvas cardíacas, cirurgia.

ABSTRACT

Mitral valve replacement has been performed for the last 30 years using an aortic designed valve, to fulfil specific requirements of the left ventricle. The clinical results obtained by such devices have been generally favorable, although specific restrictions are obvious because of their design. The knowledge and experience acquired by Biocor Laboratories in the last two decades, in production of biological heart valve substitutes, contributed positively to the research, development and manufacture of the heterologous mitral valve substitute. This stentless heterologous mitral valve was implanted in 38 patients, without hospital mortality. Their mean age was 29 years. Female gender predominated (69%). The most common mitral dysfunction was the double mitral valve lesion (53%). Eighteen (47%) patients were in functional class III and 20 (53%) in class IV of the NYHA. There was one valve related complication (our first patient), due to disproportion of patients, large annulus and the incorrectly size chosen. This complication led us to the strict adherence of our protocol, which is based upon animal experimentation. The satisfactory operatory and clinical results, throughout this 12 months of follow-up, confirm that the stentless heterologous mitral valve is the natural mitral substitute, when considering mitral valve replacement. This first natural mitral valve substitute, tanned with a non-aldehyde tissue treatment, proved to avoid calcification and to produce no foreign reaction, hence it may be the best choice in order to obtain better quality of life and the desired valve durability. Using both, the natural design mitral valve and the non-aldehyde treatment, the last 6 patients of this series received this devicxe and is certainly hoped that, due to the more natural model and the non-calcificant and inhert tissue, patients own cells will be responsible to greatly delay tissue degeneration, providing longterm durability.

Descriptors: heart valves, mitral, surgery; heart valves, surgery.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

AGRADECIMENTO

Nossos mais sinceros agradecimentos ao Corpo Clínico, Depto. de Estatística e Publicação desta Instituição, pelo desempenho na elaboração deste manuscrito, em especial às Srtas. Cristina Gomes Gurgel e Maria Aparecida Pereira.

Trabalho realizado no Instituto Biocór. Belo Horizonte, MG, Brasil.

Apresentado ao 20º Congresso Nacional de Cirurgia Cardíaca. Maceió, AL, 2 e 3 de abril, 1993.

Laureado com o "Prêmio Nacional de Cirurgia Cardíaca -1993".

1 ADEBO, O. A. & ROSS, K. J. - Surgical treatment of ruptured mitral valve chordae: a comparison between valve replacement and valve repair. Thorac. Cardiovasc. Surg, 32: 139-142, 1984.
2 BAILEY, C. P. & BOLTON, H. F. - Surgical treatment of aortic stenosis. J. Thorac. Cardiovasc. Surg, 31: 275-281, 1956.
3 BRUNTON, L. - Possibility of treating mitral stenosis by surgical methods. Lancet, 1: 352-547, 1902.
4 CARABELLO, B. A.; USHER, B. W.; HENDRIX, G. H.; ASSEY, M. E.; CRAWFORD, F. A.; LEAMAN, R. B. - Predictors of outcome in patients with aortic regurgatation and left ventricular dysfunction: a change in the measuring stick. J. Am. Coll. Cardiol, 10: 991-997, 1987.
5 CARABELLO, B. A.; WILLIAM, H.; GASH, A. K. - Hemodynamic predictors of outcome in patients undergoing valve replacement. Circulation, 74: 1309-1316, 1986.
6 CARPENTIER, A.; DELOCHE, A.; DAUPTAIN, J. - A new reconstructive operation for correction of mitral and tricuspid insufficiency. J. Thoracic. Cardiovasc. Surg, 61: 1-9, 1971.
7 DAVID, T. E. - Mitral valve replacement with preservation of chordae tendineae: rotionale and technical considerations. Ann. Thorac. Surg, 41: 680-682, 1982.
8 DAVID, T. E.; EDEN, D. E.; STRAUSS, H. D. - The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation. Circulation, 68 (Supl. 2): 76-82, 1983.
9 DAVID, T. E.; STRAUSS, A. D.; MESHER, E.; ANDERSON, M. J.; MACDONALD, I. L.; BUDA, A. J. - Is it important to preserve the chordae tendineae and papillary muscles during mitral valve replacement? Can. J. Surg, 24: 236-239, 1981.
10 DURAN, C. G. & UBAGE, J. L. M. - Clinical and hemodynamic performance of a totally flexible prosthetic ring for atrioventricular valve reconstruction. Ann. Thorac. Surg, 22: 458-465, 1976.
11 GLOVER, R. P. & DAVILA, J. C. - The treatment of mitral insufficiency by the purse. String technique: initial clinical application. J. Thorac. Surg, 33: 75-80, 1957.
12 GREGORI Jr., F.; TAKEDA, R. T.; SILVA, S. S.; FAÇANHA, L. A.; RIBEIRO, J. A.; AQUINO, W. F.; SHIGUERU, S.; GOIS, L. E.; SIQUEIRA, J. E.; KRELING, P. A.; GOULART, M. P.; FABIANO, M.; GRULAN, A. I.; MIGUITA, L. C.; CANESIN, O. - Sete anos de experiência com plastia de valva mitral. Arq. Bras. Cardiol, 47: 269-274, 1986.
13 ISOM, O. W.; DEMOBROW, J. M.; GLASSMAN, E.; PASTERNACK, B. S.; SACKLER, J. P.; SPENCER, F. C. - Factors influencing long term survival after isolated aortic valve replacement. Circulation, 50 (Supl. 2): 154-162, 1974.
14 OLIVEIRA, D. B. G.; DAWKINS, K. D.; KAY, P. H.; PANETH, M. - Chordal rupture: comparison between repair and replacement. Br. Heart J, 50: 318-324, 1983.
15 OURY, J. H.; PETERSON, K. L.; FOLKERTH, T. L.; DAILY, P. O. - Mitral valve replacement versus reconstruction: an analysis of indications and results of mitral valve procedures in a consecutive series of 80 patients. J. Thorac. Cardiovasc. Surg, 73: 256-235, 1977.
16 ROSS, D. N. - Hitorical perspective of surgery on mitral valve. In: Duran, C. (ed.) Recent progress in mitral valve disease New York, Butter Worths, 1984. p. 5-9.
17 RZPICH, J.; CARABELLO, B.; USHER, B.; KRATZ, J.; BELL, A.; ZILE, M. A. - Mechanism by which ejection performance is preserved following mitral valve repair but not replacement for chronic mitral regur-gitation. Circulation, 84 (Supl. 2): 578, 1991. (Resumo).
18 SOUTTAR, H. S. - Surgical treatment of mitral stenosis. Br. Med. J, 2: 603-609, 1925.
19 TUFFIER, T. - Actual de la chirurgie intra-thoracique. International Congress of Medicine. (Transactions). London, 1914. Seção 7 (Surgery), Parte 2, p. 249.
20 VRANDECIC, M.; GONTIJO, B.; FANTINI, F. A.; GUTIERREZ, C.; PAULA E SILA, J. A.; BARBOSA, J. T.; ANDRADE, C. A. O. - Anatomically complete heterograft mitral valve substitute: surgical technique and immediate results. J. Heart Valve Dis, 1: 254-259, 1992.
21 VRANDECIC, M.; GONTIJO, B.; PAULA E SILVA, J. A. - Clinical results with the Biocor porcine bioprosthesis. J. Cardiovasc. Surg, 32: 807-813, 1991.
22 VRANDECIC, M.; GONTIJO, B.; PAULA E SILVA, J. A. - Clinical results with the use of the Biocor bioprosthesis: a multicentric study. In: D'ALESSANDRO, L. C. - Heart Surgery, 1989. p. 227-242.
23 VRANDECIC, M.; GONTIJO, B.; RABELO, S. - Clinical experience with a new generation of porcine bioprosthesis. In: BODNAR E. & YACOUB M. (eds.) Biologic bioprosthetic valves: International Symposium 3ş (Procedimings). New York, York Medical Books, 1986. p. 559-665.

Endereço para separatas:

Mário Vrandecic

Caixa Postal 106. 30161-970 Belo Horizonte, MG, Brasil

Datas de Publicação

Publicação nesta coleção
17 Fev 2011
Data do Fascículo
Jun 1993

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1 ADEBO, O. A. & ROSS, K. J. - Surgical treatment of ruptured mitral valve chordae: a comparison between valve replacement and valve repair. Thorac. Cardiovasc. Surg, 32: 139-142, 1984.

[2] 2 BAILEY, C. P. & BOLTON, H. F. - Surgical treatment of aortic stenosis. J. Thorac. Cardiovasc. Surg, 31: 275-281, 1956.

[3] 3 BRUNTON, L. - Possibility of treating mitral stenosis by surgical methods. Lancet, 1: 352-547, 1902.

[4] 4 CARABELLO, B. A.; USHER, B. W.; HENDRIX, G. H.; ASSEY, M. E.; CRAWFORD, F. A.; LEAMAN, R. B. - Predictors of outcome in patients with aortic regurgatation and left ventricular dysfunction: a change in the measuring stick. J. Am. Coll. Cardiol, 10: 991-997, 1987.

[5] 5 CARABELLO, B. A.; WILLIAM, H.; GASH, A. K. - Hemodynamic predictors of outcome in patients undergoing valve replacement. Circulation, 74: 1309-1316, 1986.

[6] 6 CARPENTIER, A.; DELOCHE, A.; DAUPTAIN, J. - A new reconstructive operation for correction of mitral and tricuspid insufficiency. J. Thoracic. Cardiovasc. Surg, 61: 1-9, 1971.

[7] 7 DAVID, T. E. - Mitral valve replacement with preservation of chordae tendineae: rotionale and technical considerations. Ann. Thorac. Surg, 41: 680-682, 1982.

[8] 8 DAVID, T. E.; EDEN, D. E.; STRAUSS, H. D. - The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation. Circulation, 68 (Supl. 2): 76-82, 1983.

[9] 9 DAVID, T. E.; STRAUSS, A. D.; MESHER, E.; ANDERSON, M. J.; MACDONALD, I. L.; BUDA, A. J. - Is it important to preserve the chordae tendineae and papillary muscles during mitral valve replacement? Can. J. Surg, 24: 236-239, 1981.

[10] 10 DURAN, C. G. & UBAGE, J. L. M. - Clinical and hemodynamic performance of a totally flexible prosthetic ring for atrioventricular valve reconstruction. Ann. Thorac. Surg, 22: 458-465, 1976.

[11] 11 GLOVER, R. P. & DAVILA, J. C. - The treatment of mitral insufficiency by the purse. String technique: initial clinical application. J. Thorac. Surg, 33: 75-80, 1957.

[12] 12 GREGORI Jr., F.; TAKEDA, R. T.; SILVA, S. S.; FAÇANHA, L. A.; RIBEIRO, J. A.; AQUINO, W. F.; SHIGUERU, S.; GOIS, L. E.; SIQUEIRA, J. E.; KRELING, P. A.; GOULART, M. P.; FABIANO, M.; GRULAN, A. I.; MIGUITA, L. C.; CANESIN, O. - Sete anos de experiência com plastia de valva mitral. Arq. Bras. Cardiol, 47: 269-274, 1986.

[13] 13 ISOM, O. W.; DEMOBROW, J. M.; GLASSMAN, E.; PASTERNACK, B. S.; SACKLER, J. P.; SPENCER, F. C. - Factors influencing long term survival after isolated aortic valve replacement. Circulation, 50 (Supl. 2): 154-162, 1974.

[14] 14 OLIVEIRA, D. B. G.; DAWKINS, K. D.; KAY, P. H.; PANETH, M. - Chordal rupture: comparison between repair and replacement. Br. Heart J, 50: 318-324, 1983.

[15] 15 OURY, J. H.; PETERSON, K. L.; FOLKERTH, T. L.; DAILY, P. O. - Mitral valve replacement versus reconstruction: an analysis of indications and results of mitral valve procedures in a consecutive series of 80 patients. J. Thorac. Cardiovasc. Surg, 73: 256-235, 1977.

[16] 16 ROSS, D. N. - Hitorical perspective of surgery on mitral valve. In: Duran, C. (ed.) Recent progress in mitral valve disease New York, Butter Worths, 1984. p. 5-9.

[17] 17 RZPICH, J.; CARABELLO, B.; USHER, B.; KRATZ, J.; BELL, A.; ZILE, M. A. - Mechanism by which ejection performance is preserved following mitral valve repair but not replacement for chronic mitral regur-gitation. Circulation, 84 (Supl. 2): 578, 1991. (Resumo).

[18] 18 SOUTTAR, H. S. - Surgical treatment of mitral stenosis. Br. Med. J, 2: 603-609, 1925.

[19] 19 TUFFIER, T. - Actual de la chirurgie intra-thoracique. International Congress of Medicine. (Transactions). London, 1914. Seção 7 (Surgery), Parte 2, p. 249.

[20] 20 VRANDECIC, M.; GONTIJO, B.; FANTINI, F. A.; GUTIERREZ, C.; PAULA E SILA, J. A.; BARBOSA, J. T.; ANDRADE, C. A. O. - Anatomically complete heterograft mitral valve substitute: surgical technique and immediate results. J. Heart Valve Dis, 1: 254-259, 1992.

[21] 21 VRANDECIC, M.; GONTIJO, B.; PAULA E SILVA, J. A. - Clinical results with the Biocor porcine bioprosthesis. J. Cardiovasc. Surg, 32: 807-813, 1991.

[22] 22 VRANDECIC, M.; GONTIJO, B.; PAULA E SILVA, J. A. - Clinical results with the use of the Biocor bioprosthesis: a multicentric study. In: D'ALESSANDRO, L. C. - Heart Surgery, 1989. p. 227-242.

[23] 23 VRANDECIC, M.; GONTIJO, B.; RABELO, S. - Clinical experience with a new generation of porcine bioprosthesis. In: BODNAR E. & YACOUB M. (eds.) Biologic bioprosthetic valves: International Symposium 3ş (Procedimings). New York, York Medical Books, 1986. p. 559-665.

Brasil

Brasil

Transplante de valva mitral heteróloga: Nova alternativa cirúrgica: estudo clínico inicial

Heterologous mitral valve transplant: New surgical technique: initial clinical trial

Resumos

Endereço para separatas:

Datas de Publicação