{"id":8115,"date":"2018-07-10T09:30:38","date_gmt":"2018-07-10T09:30:38","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=8115"},"modified":"2018-07-10T09:32:07","modified_gmt":"2018-07-10T09:32:07","slug":"bicuspidia-aortica-ce-noutati-sunt-pentru-bolnavii-si-cardiologii-romani","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/bicuspidia-aortica-ce-noutati-sunt-pentru-bolnavii-si-cardiologii-romani\/","title":{"rendered":"Bicuspidia aortic\u0103:\u00a0ce nout\u0103\u0163i sunt pentru bolnavii \u015fi cardiologii rom\u00e2ni?"},"content":{"rendered":"

\"\"<\/a>Interviu cu Cerin Gheorghe, MD, PhD, FESC, medic primar cardiolog \u015fi doctor \u00een \u015ftiin\u0163e medicale,director \u015ftiin\u0163ific \u015fi cardiolog consultant la Centrul Cardiovascular, Spitalul Monza Bucure\u015fti \u015fi \u015feful Departamentului de Cardiologie \u015fi Medicin\u0103 Intern\u0103 Clinica San Gaudenzio Novara, Italia<\/em><\/p>\n

D-le dr Cerin, am v\u0103zut c\u0103 la Congresului Na\u0163ional de Cardiologie Sinaia 2017, sunte\u0163i prezent cu o sesiune live-in-a-box privind chirurgia reparativ\u0103 a aortei bicuspide. Ne pute\u0163i spune de ce s-a ales tocmai valva aortic\u0103? \u015etiam c\u0103 subiectul Dvs preferat era mitrala\u2026Este o sesiune \u00eent\u00e2mpl\u0103toare sau a fost o alegere \u0163intit\u0103? <\/em><\/strong><\/p>\n

Sesiunea live-in-a-box privind chirurgia reparatorie a valvei aorte de la Sianaia nu este o alegere \u00eent\u00e2mpl\u0103toare. Ea a fost propus\u0103 de mine \u015fi acceptat\u0103 de SRC deoacere de peste un deceniu la nivel interna\u0163ioal orientarea chirurgilor \u015fi a cardiologilor vis-a-vis de tratamentul chirurgical al valvei aortice a \u00eenceput s\u0103 se schimbe. De aceea am propus aceast\u0103 sesiune, oferind astfel posibilitatea colegilor din Rom\u00e2nia s\u0103 fie la curent cu tendin\u0163ele actuale din tratamentul chirurgical al aortei. \u00cen plus, am ales formatul live-in-a-box, care este ceva intermediar \u00eentre un workshop \u015fi o sesiune clasic\u0103, deoarece acesta ofer\u0103 posibilitatea auditoriului de a vedea pe viu despre ce vorbim din punct de vedere tehnic chirurgical \u015fi ecocardiografic.<\/p>\n

A\u015f zice c\u0103 din multe puncte de vedere nu a fost a\u015fa de u\u015for s\u0103 o organiz\u0103m, dar \u00een final am reu\u015fit\u2026<\/p>\n

Mai mult chiar, profit\u00e2nd de faptul c\u0103 cel de-al 13-lea Annual Meeting of the Euro-Asian Bridge Society <\/em>se \u0163ine anul acesta \u00een aceea\u015fi perioad\u0103 \u00een Rom\u00e2nia, la Ia\u015fi, am propus acela\u015fi lucru \u015fi\u00a0 d-lui Prof Grigore Tinic\u0103, pre\u015fedintele acestui prestigios Congres Regional de Chirurgie Cardiac\u0103. Propunerea noastr\u0103 a fost acceptat\u0103, de data aceasta chiar ca transmisie \u00een direct din sala de opera\u0163ii a Spitalului Monza, de unde prof Hans-Joachim Sch\u00e4fers, \u00eempreun\u0103 cu echipa de la Monza-Bucure\u015fti va efectua in live streaming o reparare de valva aortic\u0103 bicuspid\u0103.<\/p>\n

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Prof Schafers si echipa spitalului Monza in sal\u0103, la un caz de plastie de aorta bicuspid\u0103<\/figcaption><\/figure>\n

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\"\"<\/a>
Prof Schafers, dr Cerin \u00een sala operatori<\/figcaption><\/figure>\n

\u00a0<\/em><\/p>\n

Aceast\u0103 transmisie la Ia\u015fi va avea loc \u00een preziua sesiunii organizate la Congresul Na\u0163ional de Cardiologie de la Sinaia. Colegii rom\u00e2ni de la ambele congrese, ca \u015fi invita\u0163ii str\u0103ini vor avea astfel posibilitatea s\u0103 pun\u0103 \u00eentreb\u0103ri \u00een timp real echipei chirurgicale pentru a-\u015fi l\u0103muri eventualele puncte neclare. Credem c\u0103 o astfel de ini\u0163iativ\u0103 este stimulant\u0103 pentru colegii no\u015ftri \u015fi c\u0103 va reu\u015fi s\u0103 atrag\u0103 aten\u0163ia asupra unui subiect care devine din ce \u00een ce mai actual. Iar prezen\u0163a \u00een sala de opera\u0163ie \u015fi de congres a Prof Sch\u00e4fers va fi o bun\u0103 ocazie pentru a ne clarifica lucrurile privind chirurgia reparativ\u0103 a valvei aortice.<\/p>\n

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Care a fost atunci motivul adev\u0103rat pentru care a\u0163i ales aceast\u0103 tem\u0103?<\/em><\/strong><\/p>\n

A\u015f \u00eencepe cu faptul c\u0103 protezarea mecanic\u0103 a valvei aortice este perceput\u0103 din ce \u00een ce mai mult \u00een ultima vreme ca o solu\u0163ie penalizant\u0103 pentru bolnavi, mai ales pentru cei tineri\u2026M\u0103 refer \u00een primul r\u00e2nd la femeile tinere, care a\u015fa cum se \u015ftie, odat\u0103 protezate mecanic pierd dreptul de a mai avea o sarcin\u0103, \u00een afara riscului de complica\u0163ii tardive legat de protezare. De aceea \u00een ultima vreme, au ap\u0103rut dou\u0103 tendi\u0163e: alternativa ceva mai simpl\u0103 \u015fi mai frecvent\u0103 a protez\u0103rii biologice (pentru a evita cel pu\u0163in tratamentul anticoagulant) \u015fi \u00eencercarea de a salva valva aortic\u0103 a bolnavului, a\u015fa numit\u0103 \u2018aortic valve sparing surgery\u2019.<\/p>\n

Ambele sesiuni sunt virtual adresate bolnavilor cu valva aortic\u0103 bicuspid\u0103, adic\u0103 a circa 1-2% din oamenii din Rom\u00e2nia: ceva \u00een jurul a aproximativ 17.000, ori 20.000 de bolnavi. Ce facem ast\u0103zi cu ace\u015fti bolnavi \u00een Rom\u00e2nia? Cum este mai bine s\u0103 \u00eei trat\u0103m? Cum sunt opera\u0163i ei \u00een Europa \u015fi \u00een lume? Sesiunile amintite \u00ee\u015fi propun deci s\u0103 clarifice avantajele \u015fi dezavantajele chirurgiei reparative, comparativ cu standardul actual – chirurgia protezic\u0103, ceea ce a\u015f \u00eencera \u015fi eu s\u0103 fac \u00een acest interviu.<\/p>\n

Apropo\u2019 de alte \u0163\u0103ri europene; cum suntem situa\u0163i noi \u00een chirurgia reparativ\u0103 a aortei?<\/em><\/strong><\/p>\n

Aceste sesiuni au fost propuse \u015fi pentru faptul c\u0103 Rom\u00e2nia nu are ast\u0103zi un centru dedicat chirurgiei reparatorii de valva aortic\u0103, la fel cum se \u00eent\u00e2mpl\u0103 de altfel \u00een majoritatea \u0163\u0103rilor din Europa. Ca peste tot, \u015fi \u00een Rom\u00e2nia \u00een mod ocazional \u015fi \u00een cazuri bine selec\u0163ionate \u2013 adic\u0103 la bolnavi cu valve suple la eco, se practic\u0103 aceste interven\u0163ii de chirurgie reparativ\u0103, dar nu exist\u0103 \u00eenc\u0103 un centru cu experien\u0163\u0103 specific\u0103 pe acest tip de\u00a0 chirurgie. De aceea am profitat de disponibilitatea prof Hans-Joachim Sch\u00e4fers de la Universitatea din Homburg \u2013 centru european dedicat chirurgiei aortice reparatorii, \u015fi am organizat aceast\u0103 sesiune cu prezentarea unui caz clinic \u00een variant\u0103 live-in-a-box \u015fi live streaming, \u00een paralel cu c\u00e2teva conferin\u0163e strict legate de subiectul valv\u0103 aortic\u0103 bicuspid\u0103, prezentate de Dr Ana Fruntelat\u0103, dr Horia Muresian, dr Theodor Cebotaru, dr Dana Constantinescu \u015fi de mine.<\/p>\n

Spune\u0163i c\u0103 standardul actual cu protezare mecanic\u0103 sau biologic\u0103 nu rezolv\u0103 problema. Ce riscuri implic\u0103 ele pentru bolnavi? Pute\u0163i fi mai precis? C\u00e2t sunt de frecvente aceste complica\u0163ii la bolnavii proteza\u0163i?<\/strong><\/em><\/p>\n

Mai \u00eent\u00e2i trebuie spus c\u0103 \u00een toat\u0103 lumea se repar\u0103 aorta cu insuficien\u0163\u0103 valvular\u0103, c\u00e2nd nu are degenerare calcific\u0103 important\u0103, iar c\u00e2nd bicuspidia aortic\u0103 are stenoz\u0103, este tratat\u0103 practic cu protezare. Introducerea protezelor valvulare \u00een tratamentul valvulopatiilor a fost v\u0103zut\u0103 acum cinci \u2013 \u015fase decenii ca o solu\u0163ie definitiv\u0103 \u00een chirurgia leziunilor valvulare, vorbind evident de protezele mecanice, pentru c\u0103 cele biologice, cum se \u015ftie au o durat\u0103 limitat\u0103 \u00een timp\u2013de circa 16 ani pentru ultimele genera\u0163ii de proteze.<\/p>\n

Ca de obicei \u00eens\u0103 proba timpului ar\u0103ta c\u0103 lucrurile NU stau chiar a\u015fa\u2026<\/p>\n

Bolnavii cu mono proteze aortice sau mitralice, mecanice sau biologice, prezint\u0103 complica\u0163ii majore la circa jum\u0103tate din cazuri \u00een primii zece ani de la opera\u0163ie, care ajung \u00eens\u0103 la aproape trei sferturi, dac\u0103 pacien\u0163ii sunt urm\u0103ri\u0163i pe o perioad\u0103 de 15 ani. O spune studiul efectuat de Hammermeister pe 575 de bolnavi cu monoproteze aortice sau mitrale, publicat \u00een JACC acum 7 ani, care a ar\u0103tat c\u0103 ace\u015fti bolnavi urm\u0103ri\u0163i 15 ani de zile prezentau diverse complica\u0163ii majore tardive, unele grave \u015fi amenin\u0163\u0103toare de via\u0163\u0103: s\u00e2ngerare, endocardita, embolie sistemic\u0103, obstruc\u0163ia non trombotic\u0103 a protezelor, regurgitarea sau trombozarea acestora. Trebuie s\u0103 recunoa\u015ftem c\u0103 un procent de 50% de complica\u0163ii majore la bolnavii proteza\u0163i la 10 ani \u015fi de aproape trei sferturi la 15 ani, sunt procente mari \u015fi justific\u0103 pe deplin \u00eencerc\u0103rile de a g\u0103si variante alternative protezarii valvei aortice.<\/p>\n

Iat\u0103 cum aorta \u015fi chirurgia acesteia, tinde s\u0103 urmeze \u00een timp ceea ce s-a \u00eent\u00e2mplat cu mitrala, care este reparat\u0103 ast\u0103zi \u00een mod curent, cu cifre de mortalitate mici \u015fi rezultate foarte bune la follow up. Din acest punct de vedere \u015fi \u00een Rom\u00e2nia avem experien\u0163\u0103 \u00een mai multe centre, unde mitrala se repara bine, inclusiv \u00een tehnica de mini-inavziv\u0103, ceea ce nu putem spune \u00eens\u0103 \u015fi despre chirurgia reparativa a aortei. De aceea ne-am propus ca la Spitalul Monza din Bucure\u015fti s\u0103 realiz\u0103m un Centru dedicat chirurgiei reparatorii de valva aortic\u0103. A\u015fa cum acum doi ani ne propuneam tot la Monza-Bucure\u015fti s\u0103 cream un Centru dedicat cardiomiopatiilor hipertrofice, asista\u0163i de prof Paolo Ferrazzi, ast\u0103zi, colabor\u00e2nd cu Universitatea din Homburg, \u00een spe\u0163\u0103 cu prof Hans-Joachim Sch\u00e4fersdorim s\u0103 implement\u0103m acest Centru la Bucure\u015fti. Dr Lucian Doroban\u0163u, coordonator al Centrului pentru Cardiomiopatia Hipertofic\u0103, \u00eempreun\u0103 cu Prof Ferrazzisi sub \u00eendrumarea direct\u0103 a acestuia, au operat de la \u00eenfiin\u0163area Centrului \u015fi p\u00e2n\u0103 \u00een prezent 31 de bolnavi cu cardiomiopatie hipertrofic\u0103, cu rezultate identice cu cele ale centrelor consacrate \u00een lume. S\u0103 nu uit\u0103m ca \u015fi \u00een cazul cardiomiopatiei hipertrofice sunt multe \u0163\u0103ri care nu au centre dedicate acestei chirurgii deosebit de complexe\u2026Dorim a\u015fadar s\u0103 realiz\u0103m la Spitalul Monza acest nou proiect ambi\u0163ios, care va fi dedicat chirurgiei reparative a valvei aortice, sub coordonarea dr Theodor Cebotaru \u015fi \u00eendrumarea direct\u0103 a prof Sch\u00e4fers.<\/p>\n

\"\"<\/a>
Prof Schafers cu dr T Cebotaru la ie\u015firea din sala operatorie\u00a0\u00a0<\/em><\/figcaption><\/figure>\n
\"\"<\/a>
\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Prof Schafers cu echipa Spitalului Monza<\/em><\/figcaption><\/figure>\n

C\u00e2t este de sigur\u0103 \u00eens\u0103 repararea unei valvei aortice? De c\u00e2\u0163i ani se practic\u0103 aceast\u0103 chirurgie? Ce argumente exist\u0103 ast\u0103zi \u00een favoarea acestui tip de tratament chirurgical?<\/em><\/strong><\/p>\n

Foarte corect\u0103 \u00eentrebare, de\u015fi r\u0103spunsul ne oblig\u0103 s\u0103 facem un pic de istorie a medicinei\u2026 Primele \u00eencerc\u0103ri de reparare a aortei s-au f\u0103cut\u0103 cum aproximativ patru decenii. Se adresau \u00een principal regurgit\u0103rii valvei la bolnavi cu dilatarea anevrismatic\u0103 a r\u0103d\u0103cinii aortice \u015fi aortei ascendente \u015fi mai pu\u0163in cazurilor izolate, cu patologie strict valvular\u0103. Mai \u00eent\u00e2i a fost Frater \u00een 1986, cu tehnica remodel\u0103rii jonc\u0163iunii sinu-tubulare, apoi Tirone David \u00een 1992 – ideatorul tehnicii de reimplantare a r\u0103d\u0103cinii aortice (\u00eentr-un tub de dacron) \u015fi un an mai t\u00e2rziu Magdi Yacoub \u00een 1993 \u2013 cu tehnica de remodelare a r\u0103d\u0103cinii aortei. Ei sunt \u015fi ast\u0103zi considera\u0163i pionierii acestei chirurgii, fiind puncte de referin\u0163\u0103 \u00een chirurgia aortic\u0103 reparativ\u0103, de\u015fi tehnicile lor se adresau aortei tricuspide.\u00a0 Dintre toate aceste tehnici, cel mai bine la proba timpului rezist\u0103 tehnica de reimplantare a r\u0103d\u0103cinii aortei a lui Tirone David, deoarece stabilizeaza mult mai bine jonc\u0163iunea ventriculo-aortic\u0103 \u015fi evit\u0103 dilatarea \u00een timp a acesteia \u015fi recidiva insuficien\u0163ei. Tehnica Yacoub, las\u0103 anastomoza proximal\u0103 mai liber\u0103 \u015fi mai elastic\u0103, ceea ce protejaz\u0103 valva, dar, tocmai de aceea aceast\u0103 jonc\u0163iune se poate dilata \u00een timp, cu recidivarea regurgit\u0103rii.<\/p>\n

Nu cred c\u0103 trebuie intrat mai mult \u00een detalii \u00eens\u0103; sunt informa\u0163ii mult prea specifice, a\u015fa c\u0103 m-a\u015f opri aici.<\/p>\n

Important a\u015f zice c\u0103 din toate aceste tehnici ast\u0103zi cea mai stabil\u0103 privind recidiv\u0103 regurgit\u0103rii pare tehnica lui Tirone David, de reimplantare, \u015fi ca \u00een Rom\u00e2nia, \u00een lipsa unui centru profilat pe acest tip de interven\u0163ii, ele r\u0103m\u00e2n extrem de rar practicate. A\u015f mai sublinia faptul c\u0103 acestea sunt interven\u0163ii deosebit de complexe, care cer mult\u0103 expertiz\u0103 din partea \u00eentregii echipe \u015fi au timpi lungi de clampaj aortic. Fiind a\u015fadar deosebit de complexe \u015fi greu de reprodus, ele sunt la nivel interna\u0163ional ast\u0103zi considerate ca apanajul unor centre dedicate acestui tip de chirurgie. Alternativa comun\u0103 aici este opera\u0163ia clasic\u0103, Bentall, de obicei cu protez\u0103 mecanic\u0103.<\/p>\n

Ce \u015ftim despre bolnavii cu bicuspide aortic\u0103 opera\u0163i? Dar despre cei neopera\u0163i?<\/em><\/strong><\/p>\n

Istoria natural\u0103 a bolnavilor neopera\u0163i arat\u0103 ca pe termen lung ei au o rat\u0103 de mortalitate care apare identic\u0103 cu popula\u0163ia normal\u0103 \u2013 circa 90% supravie\u0163uire la 20 ani (Michelena, Circulation 2008). Urm\u0103ri\u0163i \u00een acest interval de timp \u00eens\u0103, aproximativ 40% din ei prezint\u0103 evenimente cardiace, \u00een primis nevoia unei interven\u0163ii chirurgicale, apoi insuficien\u0163\u0103 cardiac\u0103 sau alte simptome noi. Procentul evenimentelor cardiace cre\u015fte la peste 70% \u00eens\u0103 la 20 de ani, \u00een cazul bolnavilor care aveau deja degenerarea ecocardiografic\u0103 a valvei la intrarea \u00een studiu. Iar acesta este un mesaj extrem de important pentru cine are \u00een urm\u0103rire ace\u015fti bolnavi! Nu au existat cazuri de disec\u0163ie aortic\u0103, de\u015fi aorta peste 40 mm \u00een diametru, a aparut \u00een timp la circa 40% din bolnavi.<\/p>\n

Primele cazuri de reparare de aort\u0103 bicuspid\u0103 apar relativ recent, \u00een perioada anilor 1992. De aceea chirurgia reparativ\u0103 la bicuspidia aortic\u0103, practicat\u0103 cum spuneam \u00een pu\u0163ine centre, are ast\u0103zi un follow-up restr\u00e2ns. Avem date de follow-up la 5 \u015fi 10 ani pe un lot de 316 bolnavi cu bicuspidie, publicate \u00een Circulation de grupul prof Sch\u00e4fers \u00een anul 2011. Ace\u015fti bolnavi fuseser\u0103 opera\u0163i cu tehnicile chirurgicale din perioda anilor 1995\u20132008, care a\u015fa cum \u015ftim, au evoluat ulterior. Supravie\u0163uirea la acest grup, cu v\u00e2rst\u0103 medie de 49 de ani, a fost bun\u0103 la 5 ani \u015fi la 10 ani: 99% \u015fi 92%. Mortalitatea la interven\u0163ie a fost de 0,6%.<\/p>\n

Recidiva regurgit\u0103rii aortice a fost \u00eens\u0103 cauza principal\u0103 care a determinat reopera\u0163ia; stenozarea valvei reparate nefiind practic semnalatal\u0103 10 ani. Libertatea de reopera\u0163ie la 5 ani a fost de 88% \u015fi de 81% la 10 ani. Dac\u0103 vom compara rezultatele bolnavilor cu aort\u0103 reparat\u0103 \u00eens\u0103, cu cele ale pacien\u0163ilor proteza\u0163i biologic, trebuie remarcat c\u0103 la aceea\u015fi categorie de v\u00e2rst\u0103 (relativ t\u00e2n\u0103r\u0103 – bolnavi sub 50 ani = 63% circa), reoperarea dup\u0103 protezarea biologic\u0103 este destul de frecvent\u0103, fiind semnalat\u0103 \u00een literatur\u0103 \u00eentre 33% \u015fi 68%. Destul de des a fost posibil\u0103 \u00eens\u0103 repararea pentru a doua oar\u0103 a valvei: 14 din 33 de bolnavi. Libertatea de protezare aortic\u0103 la fost de 95% la 5 ani \u015fi de 84% la 10 ani.<\/p>\n

Avem \u00eens\u0103 c\u00e2teva elemente care pot indentifica bolnavii la risc de recidiv\u0103 a regurgit\u0103rii: orientarea asimetric\u0103 a celor dou\u0103 comisuri, sub un unghi de 160\u00b0 – deoarece unghiul ascu\u0163it creaz\u0103 tensiune \u015fi rezisten\u0163\u0103 \u00een plus pe una din cele dou\u0103 cuspide, ca \u015fi tractul de eflux al ventriculului st\u00e2ng l\u0103rgit, cu un diametru de peste 29mm, deoarece \u00een timp dilatarea acestei zone progreseaz\u0103, determind alterarea geometriei valvei aortice cu recidiva regurgit\u0103rii. Recidiva regurgit\u0103rii este corelat\u0103 \u00een plus cu diverse aspecte tehnice chirurgicale: lipsa strategiei de substituire a r\u0103d\u0103cinii aortice, dar \u015fi folosirea plic\u0103turii subcomisurale sau a extensiei de foi\u0163e cu pericard, la care de fapt grupul a renun\u0163at \u00een timp. Cazurile la care s-a folosit tehnica Yacoub de remodelarea r\u0103d\u0103cinii aortice au fost mult mai stabile \u00een timp fa\u0163\u0103 de bolnavii la care nu s-a folosit aceast\u0103 tehnic\u0103.<\/p>\n

Pe baza acestor observa\u0163ii \u00eencep\u00e2nd cu anii 2005-2006 acest grup a \u00eenceput s\u0103 foloseasc\u0103 o nou\u0103 tehnic\u0103 de stabilizare a jonc\u0163iunii ventriculo-aortice folosind un fir din goretex, plasat circular \u00een aceast\u0103 zon\u0103, str\u00e2ns apoi pe un calibrator Hegar. Acela\u015fi pricipiu \u015fi \u00een aceea\u015fi perioad\u0103 a fost aplicat de \u015fcoal\u0103 franceza, prin inelul prof Lansac. Cum vedem lucrurile prinvind chirurgia reaparativ\u0103 a aortei sunt \u00een plin\u0103 mi\u015fcare, iar rezultatele \u015fi follow-up-ul ultimelor achizi\u0163ii conceptuale \u015fi de tehnic\u0103 chirurgical\u0103 sunt a\u015fteptate cu interes de \u00eentreaga clas\u0103 medical\u0103. Cred de aceea c\u0103 aceste dou\u0103 sesiuni dedicate chirurgiei reparative de la Sinaia \u015fi de la Ia\u015fi se justific\u0103 pe deplin.<\/p>\n

Cum de a\u0163i ajuns s\u0103 colabor\u00e2\u0163i \u00eens\u0103 cu d-l Prof Sch\u00e4fers? \u015etim c\u0103 Dvs lucra\u0163i in Italia, nu \u00een Germania\u2026 Ce alte personalit\u0103\u0163i \u015fi puncte de referin\u0163\u0103 \u00een chirurgia reparativ\u0103 a aortei avem \u00een Europa?<\/em><\/strong><\/p>\n

Va trebui mai \u00eent\u00e2i s\u0103 \u00eemi permite\u0163i o considera\u0163ie personal\u0103, care \u0163ine poate \u015fi de faptul c\u0103 lucrez \u00eentr-un sistem privat de peste 25 de ani. A\u015f spune c\u0103 medicina privat\u0103, poate mult mai mult chiar dec\u00e2t de cea public\u0103 \u015fi chiar cea universitar\u0103, este peste tot \u00een lume atent\u0103 la nout\u0103\u0163ile medicale \u015fi caut\u0103 astfel s\u0103 colaboreze cu centre \u015fi personalit\u0103\u0163i considerate de referin\u0163\u0103 \u015fi de avangard\u0103 \u00een lume. Pentru c\u0103 sistemul privat \u00een sine permite o mai mare rapiditate \u015fi elasticitate decizional\u0103. De aceea a\u015f zice c\u0103 nu mai este esen\u0163ial cum l-am cunoscut pe prof Sch\u00e4fers… Mult mai important este c\u0103 dansul a acceptat invita\u0163ia noastr\u0103\u00a0 acum, ca \u015fi anul trecut, c\u00e2nd a fost disponibil s\u0103 opereze \u00een direct streaming, din Germania un caz de hipertensiune pulmonar\u0103 sever\u0103 post embolic\u0103, pentru Congresul Na\u0163ional de Cardiologie Sinaia 2016. Interven\u0163ie chirurgical\u0103 rar\u0103 \u015fi extrem de interesant\u0103, care a avut evident sala plin\u0103, fiind \u015fi aceasta doar ocazional practicat\u0103 \u00een Rom\u00e2nia – la Timi\u015foara, de prof Ga\u015fpar. Cu mul\u0163i ani \u00eenainte de a-l cunoa\u015fte personal \u015ftiam de valoarea profesional\u0103 a d\u00e2nsului \u00een mod direct prin dr Clara Alexandrescu de la Monte Carlo, fost\u0103 coleg\u0103 \u015fi bursier\u0103 la Novara. Prof Sch\u00e4fers este bine cunoscut \u00een lumea medical\u0103, fiind al\u0103turi de Emmanuel Lansac \u015fi de Gebrin El Khoury nume de referin\u0163\u0103 \u00een Europa \u015fi \u00een lume \u00een repararea valvei aortice.<\/p>\n

Cu prof Gebrine El Khoury de exemplu, am avut pl\u0103cerea s\u0103 colabor\u0103m \u015fi s\u0103 confrunt\u0103m pe viu experien\u0163a Clinicii San Gaudenzio din Novara pe aortic valve sparing surgery \u00een anul 2014, la EuroEcho Viena. Atunci d\u00e2nsul, \u00eempreun\u0103 cu Prof Vinereanu a fost chairman la o sesiune live streming la un caz de reparare de valv\u0103 aortic\u0103 bicuspid\u0103, efectuat \u00een direct de la Novara, av\u00e2nd \u00een sala pe dr Marco Diena, bine cunoscut \u00een colegilor din Rom\u00e2nia. Transmisia s-a bucurat de mult succes, iar opera\u0163ia ca \u015fi ecocardiografia \u00een direct au fost, ca de obicei bine cotate de auditoriu. Cu oarecare orgoliu a\u015f mai ad\u0103uga c\u0103 aceast\u0103 sesiune de succes \u015fi de avangard\u0103 a fost pe trei sferturi rom\u00e2neasc\u0103: Prof Vinereanu, dr Horia Muresian, eu, dr Diana Benea, al\u0103turi de Prof El Khoury \u015fi dr M Diena.<\/p>\n

Referitor la repararea aortei bicuspide, ce ne pute\u0163i spune despre tehnica chiurgical\u0103 a prof Sch\u00e4fers? Ce are deosebit \u00een ea \u015fi ce aduce nou aceast\u0103 tehnic\u0103?<\/em><\/strong><\/p>\n

Ceea ce m-a impresionat de la primul caz operat la care am asistat, a fost simplitatea conceptual\u0103 a acestei opera\u0163ii. Fiind congenital\u0103 – valva aortic\u0103 bicuspid\u0103 opune \u00eenc\u0103 de la na\u015ftere o rezisten\u0163\u0103 mai mare la deschidere, datorit\u0103 sud\u0103rii a dou\u0103 cuspide din trei. Astfel bicuspidia aortic\u0103 tinde s\u0103 dezvolte \u00een timp o dilatare progresiv\u0103 de jonc\u0163iune ventriculo aortic\u0103 \u015fi de inel aortic, iar odat\u0103 cu dilatarea inelului se l\u0103rge\u015fte automat suprafa\u0163a \u00eentregului orificiu valvular aortic. Dac\u0103 la un adult de talie medie avem \u00een general un inel aortic de 23 mm de exemplu, la bolnavii cu bicuspidie putem ajunge u\u015for la diametre de 27, 28 sau 30 mm. Se consider\u0103 \u00een general c\u0103 un inel aortic de peste 25 mm este dilatat. Codificarea genetic\u0103 a suprafe\u0163ei cu spidelor aortice la bolnavii cu bicuspidie \u00eens\u0103 NU sufer\u0103 \u015fi ea modific\u0103ri, ele fiind proiectate genetic s\u0103 \u201cacopere\u201d aria unui orificiu valvular mai mic, care ar corespunde unui inel \u201cstandard\u201d de 23 mm circa… Aceast\u0103 nepotrivire dintre suprafa\u0163a (mai mic\u0103) de acoperirea cuspidelor \u015fi cre\u015fterea ariei orificiului valvular la aorta bicuspid\u0103, determin\u0103 alter\u0103ri importante de geometrie ale compelxului valvular aortic \u015fi de coaptare a valvei, care genereaz\u0103 foarte frecvent insuficient\u0103 valvular\u0103, de regul\u0103 prin prolapsul cuspidei unice, de\u015fi nici cuspida non coronarian\u0103 nu r\u0103m\u00e2ne normal\u0103.<\/p>\n

De aici a plecat idea prof Sch\u00e4fers \u015fi conceptul care st\u0103 la baza tehnicii chirurgicale realizate de acesta: restr\u00e2ngerea inelului aortic cu un fir gros de sutur\u0103 circular din Goretex, aplicat la r\u0103d\u0103cin\u0103 aortei, la nivelul \u015fantului dintre ventriculul st\u00e2ng \u015fi aorta (sub sinusurile lui Valsalva \u2013 vezi foto).\u00a0 \u00cen acest fel, prin str\u00e2ngerea acestui fir circular, pe un calibrator (ca firul de la o \u201cpung\u0103 de tutun\u201d), se ob\u0163ine reducerea suprafe\u0163ei orificiului aortic, iar cuspidele redevin suficiente pentru a acoperi mai eficient aria orificiului aortic, reduc\u00e2nd mult regurgitarea. Urmeaz\u0103 apoi \u015fi un al doilea gest chirurgical: rezolvarea prolapsului, de obiecei prin simpla plicaturare a cuspidelor \u015fi reconstruirea geometriei valvulare, controlat ecografic imediat intraoperator. \u00cen cazul \u00een care interven\u0163ia se adreseaz\u0103 doar valvei aortice, opera\u0163ia are avantajul c\u0103 este de scurt\u0103 durat\u0103, lucru foarte important \u00een chirurgia cardiac\u0103, dar mai ales pentru bolnav.<\/p>\n

\"\"<\/a>
\u00a0Sutura circulara Schafers\u00a0<\/em><\/figcaption><\/figure>\n
\"\"<\/a>
Tehnica Schafers de stabilizare a inelului aortic<\/em><\/figcaption><\/figure>\n

Conceptual vorbind, a\u015fa cum aminteam \u015fi mai \u00eenainte, opera\u0163ia propus\u0103 de prof Sch\u00e4fers este foarte asem\u0103n\u0103toare cu cea propus\u0103 de \u015fcoal\u0103 francez\u0103, prin prof Lansac. Cum se \u015ftie, prof Lansac este adeptul unui inel aortic extern, care se implanteza \u00een aceea\u015fi zon\u0103 \u00een care este efectuat\u0103 sutura cu fir continuu de goretex practicat\u0103 de prof Schafres. \u015ecoala francez\u0103 rezolv\u0103 dilatarea r\u0103d\u0103cinii aortice folosind tehnica Yacoub de remodelare, care stabiliza jonc\u0163iunea sinu-tubularain partea superioar\u0103, dar care las\u0103 nerezolvat\u0103 problema inelului aortic, aflat la baza acestui complex inel-valva-cuspide-sinusuri. Implantarea acestui inel aortic extern rezolv\u0103 problema dilat\u0103rii progresive de inel aortic \u015fi astfel a reapari\u0163iei regurgit\u0103rii, semnalat\u0103 ini\u0163ial dup\u0103 tehnica de remodelare Yacoub.<\/p>\n

A\u015f spune \u00een concluzie c\u0103 subiectul chirurgie reparativ\u0103 la valva aortic\u0103 este \u00een plin\u0103 mi\u015fcare la nivel interna\u0163ional \u015fi cred c\u0103 \u00een anii care urmez\u0103 vom asista la schimb\u0103ri importante din acest punct de vedere. A venit cred momentul s\u0103 \u00eentr\u0103m \u00een r\u00e2ndul acestor centre \u015fi s\u0103 ne aliniem cu tendi\u0163ele actuale din chirurgia cardiac\u0103.<\/p>\n

Noi am ales \u015fi am avut \u015fansa s\u0103 putem colabora cu unul din aceste centre de referin\u0163\u0103. De aceea a\u015f \u00eencheia acest interviu cu un proverb italienesc care zice \u201cla scuola non e\u2019 acqua!\u201d. <\/em>Pentru c\u0103 \u015ftim foarte bine c\u0103 f\u0103r\u0103 colaborarea cu un centru de referin\u0163\u0103 \u015fi cu persoane care sunt \u00een avangard\u0103 nu vom putea ajunge la performan\u0163\u0103.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Interviu cu Cerin Gheorghe, MD, PhD, FESC, medic primar cardiolog \u015fi doctor \u00een \u015ftiin\u0163e medicale,director \u015ftiin\u0163ific \u015fi cardiolog consultant la Centrul Cardiovascular, Spitalul Monza Bucure\u015fti \u015fi \u015feful Departamentului de Cardiologie […]<\/p>\n","protected":false},"author":4,"featured_media":8126,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[81],"tags":[],"class_list":["post-8115","post","type-post","status-publish","format-standard","has-post-thumbnail","category-cardiologie"],"yoast_head":"\nBicuspidia aortic\u0103:\u00a0ce nout\u0103\u0163i sunt pentru bolnavii \u015fi cardiologii rom\u00e2ni?<\/title>\n<meta name=\"description\" content=\"Bicuspidia aortic\u0103 ne prezinta ce nout\u0103\u0163i sunt pentru bolnavii \u015fi cardiologii rom\u00e2ni\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/jurmed.ro\/medici\/bicuspidia-aortica-ce-noutati-sunt-pentru-bolnavii-si-cardiologii-romani\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Bicuspidia aortic\u0103:\u00a0ce nout\u0103\u0163i sunt pentru bolnavii \u015fi cardiologii rom\u00e2ni?\" \/>\n<meta property=\"og:description\" content=\"Bicuspidia aortic\u0103 ne prezinta ce nout\u0103\u0163i sunt pentru bolnavii \u015fi cardiologii rom\u00e2ni\" \/>\n<meta property=\"og:url\" content=\"https:\/\/jurmed.ro\/medici\/bicuspidia-aortica-ce-noutati-sunt-pentru-bolnavii-si-cardiologii-romani\/\" \/>\n<meta property=\"og:site_name\" content=\"Jurmed - 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