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Medwave 2016;16(Suppl 4):e6530 doi: 10.5867/medwave.2016.6530
Actualización en el diagnóstico por imagen de la patología valvular aórtica
Image diagnosis of aortic valve disease: an update
Miquel Gómez
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Palabras clave: aortic stenosis, echocardiography, magnetic resonance imaging, computerized tomography

Resumen

La valvulopatía aórtica es la enfermedad valvular adquirida más común y la que con mayor frecuencia precisa cirugía de recambio valvular en nuestro medio. En este capítulo se revisan las últimas aportaciones científicas en el campo de la imagen cardiaca en esta enfermedad (ecocardiografía, resonancia magnética y tomografía computarizada cardiaca), ya que algunas de ellas han suscitado amplios y animados debates en foros de discusión en los últimos años. Estas aportaciones nos han obligado a reformular algunos criterios diagnósticos, y en buena medida, a repensar el manejo de dicha patología.


 
Introducción

La patología valvular aórtica, y en concreto, la estenosis aórtica degenerativa, constituye ya la primera causa de cirugía cardíaca, además del creciente número de pacientes que son tratados de forma percutánea (implante valvular aórtico transcatéter, TAVI). El aumento de la esperanza de vida en la población está haciendo que su prevalencia esté aumentando de forma muy notable. La esclerosis de la válvula aórtica está presente en el 25% de la población entre 65 a 74 años y en el 50% de los mayores de 80 años. Por otro lado, la estenosis aórtica se da en el 2% de la población mayor de 65 años, 3% de los mayores de 75 años y en el 4% de los mayores de 85 años [1].

El desarrollo de las técnicas de imagen en cardiología ha mejorado de forma muy notable nuestro conocimiento de la enfermedad valvular aórtica. A continuación se revisan las últimas aportaciones científicas en el campo de la imagen cardiaca en esta enfermedad, tanto en el campo de la ecocardiografía, de la resonancia magnética y de la tomografía computarizada cardiaca.

Ecocardiografía

Cálculo del área valvular aórtica mediante la fórmula de continuidad
Uno de los aspectos que ha suscitado mayor controversia en la literatura reciente, en cuanto al diagnóstico de la estenosis aórtica por ecocardiografía, es el cálculo del área valvular aórtica por la fórmula de continuidad [2]. Como es bien sabido, en la determinación del diámetro del tracto de salida del ventrículo izquierdo se encuentra uno de los errores más habituales en el diagnóstico de estos pacientes. Esto es debido a la variabilidad existente en su determinación mediante ecocardiografía 2D en su eje paraesternal longitudinal. Los estudios con ecocardiografía 3D y tomografía computarizada cardiaca nos han enseñado que dicho tracto de salida tiene una forma elíptica, hecho que explica dicha variabilidad en los cálculos. La fórmula de continuidad asume que el del tracto de salida del ventrículo izquierdo es una estructura circular perfecta, lo que afectará al resultado del área valvular aórtica. Por este motivo, debemos asumir cierta limitación a la hora de valorar la severidad de la estenosis aórtica por el área valvular aórtica, y probablemente dar mayor valor diagnóstico a la velocidad máxima obtenida por Doppler continuo. Dada la gran importancia de evitar errores de clasificación en la evaluación de la severidad de la estenosis aórtica, algunos trabajos abogan por disminuir el punto de corte del área valvular aórtica a 0,8 cm2 para etiquetar como severa a la estenosis aórtica con tracto de salida del ventrículo izquierdo pequeño (entre 17 y 20 mm) [3].

Para solucionar la limitación del tracto de salida del ventrículo izquierdo, algunos estudios han demostrado que su estimación mediante eco-3D es más reproducible que con eco-2D, por lo que podría ser un método más preciso, aunque más laborioso, y así clasificar mejor la severidad de la estenosis aórtica. Además la eco-3D presenta una ventaja teórica, y es que con ella se puede realizar planimetría directa del del tracto de salida del ventrículo izquierdo [4].

Otro temas de discusión reciente es el de la necesidad de indexación del área valvular aórtica por la superficie corporal, aunque en general resulta útil, dicha indexación puede sobreestimar la severidad de la estenosis aórtica en pacientes con obesidad [5].

Estenosis aórtica a bajo flujo/bajo gradiente con función sistólica preservada
Otro de los aspectos que han suscitado mayor controversia, ha sido el de la estenosis aórtica a bajo flujo/bajo gradiente (BF/BG) con fracción de eyección preservada. Desde su descripción original [6] por Hachicha y colaboradores, en 2007, numerosos estudios han intentado aclarar si este patrón ecocardiográfico se asocia con un peor pronóstico [7]. En estos pacientes encontramos un área valvular aórtica inferior a 1 cm2 en el cálculo mediante la fórmula de continuidad, pero los gradientes transvalvulares medios son bajos (inferiores a 40 mmHg), en pacientes con fracción de eyección preservada. En un estudio reciente, Gonzalez-Cánovas y colaboradores [8], confirman mediante eco-3D, que la estenosis aórtica grave con bajo gradiente y fracción de eyección paradójicamente preservada se da en el 85% de los casos así catalogados por eco-2D, dicho de otro modo, un 15% de los pacientes están clasificados erróneamente como estenosis aórtica severa, cuando en realidad no lo son.

En estos pacientes se ha hipotetizado que podrían tener una disfunción sistólica incipiente, lo que explicaría un menor flujo y gradiente transaórtico, pese a tener fracción de eyección normal. Este hecho ha sido demostrado mediante técnicas de deformación miocárdica, ya que estos pacientes tienen un menor strain longitudinal [9],[10].

Aunque hay algunos trabajos que hipotetizan que el pronóstico de la estenosis aórtica a BF/BG puede ser peor que el de la estenosis aórtica con alto gradiente, y de que la cirugía valvular precoz mejoraría su pronóstico; en una publicación reciente, que incluía a 809 pacientes con estenosis aórtica, se observó que el pronóstico de esta a BF/BG con función sistólica preservada fue similar al de la estenosis aórtica ligera-moderada y no fue favorable la influencia de la cirugía valvular [11]. Según estos datos, no podemos decir que esta entidad sea la etapa final de la enfermedad, por lo que el manejo y la indicación de sustitución valvular aórtica, a día de hoy, debe ser valorada de forma individualizada y todavía conllevará futuros estudios.

Otros marcadores pronósticos en la estenosis aórtica
Si bien las guías clínicas [12] dejan bien claro que aquellos pacientes con estenosis aórtica severa sintomáticos, con disfunción ventricular o bien con una prueba de esfuerzo patológica, deben ser sometidos a reemplazo valvular aórtico, es un área de gran interés el desarrollo de nuevos marcadores pronósticos que permitan estratificar mejor a los pacientes afectos de estenosis aórtica que están asintomáticos o aparentemente asintomáticos. Algunos estudios recientes han demostrado que deben valorarse otros aspectos clínicos o ecocardiográficos asociados a la valvulopatía aórtica [13],[14],[15],[16]. Uno de ellos es la presencia de hipertensión pulmonar asociada en la estenosis aórtica, hecho que se da en un 30% de pacientes y que puede ser evaluada mediante ecocardiografía de esfuerzo y guiar la decisión quirúrgica en casos dudosos [14]. La detección de hipertensión pulmonar empeora el pronóstico de la enfermedad y de la cirugía valvular, si bien suele ser reversible tras la cirugía en caso de que sea secundaria a presión capilar elevada. Otro de los aspectos a considerar, y a corregir, es la presencia de anemia en los pacientes con estenosis aórtica, ya que su presencia puede tener un impacto negativo en la aparición de los síntomas asociados a la valvulopatía, así como en su pronóstico quirúrgico [15],[16]. La utilización de biomarcadores séricos, como la elevación del NT-proBNP (N-terminal-pro-Brain Natriuretic Peptide), puede ser un marcador de “sufrimiento miocárdico”, con valor pronóstico en los pacientes asintomáticos o con síntomas poco claros, lo que ayuda a guiar la decisión de indicar la cirugía [17].

En cuanto al cribado de la válvula bicúspide en familiares de primer orden, la alta prevalencia de su aparición hace que sea recomendable realizar un ecocardiograma como técnica de cribaje. En un reciente estudio, un 8% de los familiares de primer grado presentaban una aorta bicúspide, dato que refuerza la realización del screening familiar, tal y como se recoge en las guías clínicas [18].

Aportaciones de la resonancia magnética cardiaca (RM cardíaca) en valvulopatía aórtica

A día de hoy, los estudios de resonancia magnética cardíaca en pacientes con valvulopatía aórtica se centran más en el campo de la investigación que en el de la práctica clínica habitual. Aun así, ya desde los años 90 la resonancia magnética cardiaca ha sido validada para la cuantificación de la estenosis aórtica. Este examen tiende a infraestimar la velocidad máxima respecto a la señal Doppler continua del ecocardiograma, por lo que en general lo más adecuado es realizar una planimetría del área valvular aórtica, ya que numerosos estudios han mostrado una buena correlación entre la estimación del área valvular por eco-2D y resonancia magnética cardíaca.

La caracterización tisular mediante resonancia magnética cardíaca permite detectar focos de fibrosis o necrosis miocárdica mediante las secuencias de inversión-recuperación o por T1-mapping. Así, se ha comprobado que la fibrosis intramiocárdica en pacientes con estenosis aórtica es un buen predictor de mortalidad [19].

En cuanto a la insuficiencia aórtica, la resonancia magnética cardiaca es una técnica de alta precisión mediante las secuencias phase-contrast para el cálculo del volumen y la fracción de regurgitante, a pesar de que es mucho menos práctica que la ecocardiografía, dada su menor asequibilidad y eficiencia. No se recomienda para su cuantificación el área regurgitante o la longitud del jet regurgitante, ya que son parámetros poco fiables de la severidad de la regurgitación. Un estudio reciente ha demostrado una alta correlación de la resonancia magnética cardiaca con la eco-3D y algo menor con la eco-2D, en la regurgitación aórtica [20].

Tomografía computarizada del corazón en la patología valvular aórtica

El interés por la tomografía computarizada en cardiología es creciente, aunque todavía es una técnica poco utilizada en la práctica clínica habitual. Su mayor aportación radica en la evaluación diagnóstica para descartar enfermedad coronaria [21], en pacientes con riesgo bajo-intermedio, y en aquellos en los que las pruebas diagnósticas son inciertas. En patología valvular aórtica, una de sus aplicaciones es el estudio de la anatomía coronaria no invasiva antes de la cirugía valvular aórtica, con una baja dosis de irradiación (1-3 mSv) en los equipos de última generación, evitando así la realización de un cateterismo cardíaco. Asimismo, puede resultar útil en casos donde se plantea la duda de morfología bicúspide por ecocardiografía, así como para el estudio complementario de la aorta ascendente. Puede medirse también el grado de calcificación valvular aórtica, donde los depósitos de calcio se muestran como regiones brillantes y se cuantifica el calcio usando el método de Agatston. Para ello, los focos calcificados se definen como áreas de superiores o iguales a 3 píxeles, con atenuación superior a 130 unidades Hounsfield. La puntuación de calcio se calcula multiplicando el área medida por un coeficiente de atenuación y se expresa en unidades Agatston (AU) [22]. Aun así, la mayor utilidad de la tomografía computarizada en patología valvular aórtica radica en el estudio previo al intervencionismo estructural, como en el implante transcatéter de endoprótesis valvular aortica (TAVI) dada su extraordinaria resolución anatómica. Aquí la técnica ha demostrado optimizar la selección de los dispositivos, adecuarlos al tamaño del anillo aórtico y evitar complicaciones como la migración o las lesiones en la emergencia de las arterias coronarias [23].

Notas

Declaración de conflictos de intereses
El autor ha completado el formulario de declaración de conflictos intereses del ICMJE traducido al castellano por Medwave, y declara no haber recibido financiamiento para la realización del articulo; no tener relaciones financieras con organizaciones que podrían tener intereses en el artículo publicado, en los últimos tres años; y no tener otras relaciones o actividades que podrían influir sobre el artículo publicado. Los formularios pueden ser solicitados contactando al autor responsable o a la dirección editorial de la Revista.

Financiamiento
El autor declara no haber recibido financiamiento para la realización de este artículo.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

Aortic valve disease is the most common acquired valvular disease and most often requiring surgical valve replacement in our environment. In this chapter the latest scientific contributions in the field of cardiac imaging in this disease (echocardiography, magnetic resonance imaging and cardiac computed tomography) are reviewed. Some of them have aroused large and lively debates in forums in recent years. These contributions have forced us to rethink some diagnostic criteria, and the management of this disease as well.

Autor: Miquel Gómez[1,2]

Filiación:
[1] Servicio de Cardiología, Hospital del Mar Parc de Salut Mar, Barcelona, España
[2] Facultad de Medicina, Universitat Autonoma de Barcelona, Barcelona, España

E-mail: mgomezpe@parcdesalutmar.cat

Correspondencia a:
[1] Servicio de Cardiología
Hospital del Mar-Parc de Salut Mar
Paseo Marítimo 25
Barcelona
España

Citación: Gómez M. Image diagnosis of aortic valve disease: an update. Medwave 2016;16(Suppl 4):e6530 doi: 10.5867/medwave.2016.6530

Fecha de publicación: 16/9/2016

Origen: Este artículo forma parte del Suplemento 4 Especial de Cardiología cuyo editor invitado es el Dr. Alberto Morales Salinas, Cardiocentro "Ernesto Che Guevara", Villa Clara; Grupo Nacional de Cardiología, Ministerio de Salud Pública, Cuba

Ficha PubMed

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