array:20 [ "pii" => "X1134009612879091" "issn" => "11340096" "estado" => "S300" "fechaPublicacion" => "2012-10-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Cir Cardiov. 2012;19:373-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2729 "formatos" => array:3 [ "EPUB" => 49 "HTML" => 2115 "PDF" => 565 ] ] "itemSiguiente" => array:16 [ "pii" => "X1134009612879106" "issn" => "11340096" "estado" => "S300" "fechaPublicacion" => "2012-10-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Cir Cardiov. 2012;19:377-84" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2469 "formatos" => array:3 [ "EPUB" => 26 "HTML" => 1957 "PDF" => 486 ] ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Evaluación retrospectiva de la sustitución valvular tricúspide en el tratamiento de las valvulopatías adquiridas" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "377" "paginaFinal" => "384" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Retrospective evaluation of tricuspid valve replacement in the treatment of the acquired valvular diseases" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "358v19n04-90187910fig1.jpg" "Alto" => 920 "Ancho" => 1025 "Tamanyo" => 75911 ] ] "descripcion" => array:1 [ "es" => "Imagen frecuente en valvulopatía mitral y tricúspide evolucionada." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos A. Infantes" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Carlos A." "apellidos" => "Infantes" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1134009612879106?idApp=UINPBA00004N" "url" => "/11340096/0000001900000004/v0_201307100940/X1134009612879106/v0_201307100941/es/main.assets" ] "itemAnterior" => array:16 [ "pii" => "X1134009612879083" "issn" => "11340096" "estado" => "S300" "fechaPublicacion" => "2012-10-01" "documento" => "article" "crossmark" => 0 "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Cir Cardiov. 2012;19:367-71" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6377 "formatos" => array:3 [ "EPUB" => 45 "HTML" => 5829 "PDF" => 503 ] ] "es" => array:11 [ "idiomaDefecto" => true "titulo" => "La anuloplastia tricúspide: ¿De Vega, flexible o rígida?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "367" "paginaFinal" => "371" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Annuloplasty selective, adjustable and permanent. An original technique for the treatment of tricuspid insufficiency" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Manuel Bernal, Jesús Herreros" "autores" => array:2 [ 0 => array:2 [ "nombre" => "José Manuel" "apellidos" => "Bernal" ] 1 => array:2 [ "nombre" => "Jesús" "apellidos" => "Herreros" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X1134009612879083?idApp=UINPBA00004N" "url" => "/11340096/0000001900000004/v0_201307100940/X1134009612879083/v0_201307100941/es/main.assets" ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Anuloplastia tricúspide con anillo biodegradable" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "373" "paginaFinal" => "375" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Afksendiyos Kalangos" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Afksendiyos" "apellidos" => "Kalangos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Chairman, Department of Cardiovascular Surgery University Hospital of Genova" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Tricuspid Annuloplasty Using a Biodegradable Ring" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "358v19n04-90187909fig1.jpg" "Alto" => 454 "Ancho" => 1020 "Tamanyo" => 41265 ] ] "descripcion" => array:1 [ "es" => "El anillo tricúspide biodegradable." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">ANULOPLASTIA TRICÚSPIDE CON ANILLO BIODEGRADABLE</span></p><p class="elsevierStylePara"> El concepto de anillo biodegradable no es reciente. En 1983, el profesor Carpentier predijo el uso potencial de material biodegradable en la anuloplastia mitral<span class="elsevierStyleSup">1</span>, y en 1990 su equipo llevó a cabo un programa experimental de reparación valvular mitral con el empleo de un anillo absorbible de polidioxanona, similar en forma al anillo rígido de Carpentier-Edwards<span class="elsevierStyleSup">2</span>. En 1992, Duran describió los hallazgos histológicos de un estudio experimental en ovejas con el empleo de la anuloplastia tricúspide de De Vega utilizando una sutura de polidioxanona de 2-0. Este material de sutura permitió que el anillo tricúspide nativo permaneciera intacto durante los primeros tres meses y conservara sus dimensiones iniciales a los cinco meses tras la degradación parcial del anillo<span class="elsevierStyleSup">3</span>.</p><p class="elsevierStylePara"> La idea de reforzar temporalmente el anillo tricúspide usando material de sutura biodegradable fue posteriormente corroborada por Duran en un estudio clínico llevado a cabo en 73 pacientes con insuficiencia tricúspide (IT) funcional y baja resistencia pulmonar; la baja tasa de recurrencia de la IT durante un periodo de seguimiento de dos años mostró la estabilidad postoperatoria de dicha anuloplastia tricúspide<span class="elsevierStyleSup">4</span>.</p><p class="elsevierStylePara"> Aunque Carrier, et al. comunicaron de forma similar una baja tasa de fallo de la anuloplastia con buena supervivencia a largo plazo, tanto con las anuloplastias de De Vega, reductor lineal flexible de Bex o con anillo de Carpentier-Edwards<span class="elsevierStyleSup">5</span>, muchos estudios clínicos han obtenido una mayor durabilidad de la reparación y una mejor supervivencia a largo plazo usando un anillo protésico comparado con la anuloplastia de De Vega o con la bicuspidización con sutura de la válvula tricúspide<span class="elsevierStyleSup">6-9</span>.</p><p class="elsevierStylePara"> En un estudio experimental sobre IT crónica que compara el uso de un anillo de politetrafluoroetileno (PTFE) totalmente flexible, un anillo de silicona elástico, un anillo rígido de metal y el no empleo de anillo, los patrones de motilidad anular fueron similares a los de un anillo normal cuando se emplearon los anillos de PTFE y silicona; sin embargo, solo el anillo de PTFE respetó la ondulación natural del anillo nativo, mientras que los otros dos anillos forzaron el plano tridimensional del anillo hacia una posición horizontal<span class="elsevierStyleSup">10</span>.</p><p class="elsevierStylePara"> El anillo biodegradable fue concebido y desarrollado con el objetivo de preservar la geometría dinámica tridimensional tanto del anillo tricúspide como del mitral. La versión tricúspide del anillo biodegradable de Kalangos<span class="elsevierStyleSup">®</span> consta de un polímero de poli-1,4-dioxanona, dispuesto alrededor de un monofilamento de polivinilo 2-0 en continuidad a lo largo del anillo y equipado de una aguja de acero inoxidable en cada extremo (Fig. 1).</p><p class="elsevierStylePara"><img alt="Figura 1. El anillo tricúspide biodegradable." src="358v19n04-90187909fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figura 1. </span>El anillo tricúspide biodegradable.</span></p><p class="elsevierStylePara"> El peso molecular específico del material biodegradable asegura su flexibilidad tridimensional y memoria estructural frente a su deformidad posterior. La degradación gradual del material genera tejido fibroso, que produce a su vez un remodelado secundario y autólogo del anillo. De forma contraria a los anillos convencionales, el anillo biodegradable se implanta dentro del anillo nativo para promover la inflamación y su transformación secundaria en tejido fibroso.</p><p class="elsevierStylePara"> La inserción intraanular del anillo evita la liberación de partículas procedentes de la degradación en el interior de las cavidades cardíacas. Para la anuloplastia tricúspide, el implante del anillo biodegradable empieza a nivel de la comisura posteroseptal (a 2-3 mm de la inserción del velo en el anillo y a 2-3 mm en profundidad) (Fig. 2.1), haciendo avanzar la aguja hacia delante y dentro del anillo hasta el primer punto de salida (Fig. 2.2). Reinsertando la aguja en el punto de salida y tirando del material de sutura, el anillo se adelanta hasta la comisura anteroseptal y se inserta completamente en el interior del anillo nativo. Se fija anudando cada uno de los dos extremos de la sutura a nivel de las comisuras anteroseptal y posteroseptal, respectivamente (Fig. 2.3)<span class="elsevierStyleSup">11</span>.</p><p class="elsevierStylePara"><img alt="Figura 2. 1. Primer punto de entrada del anillo en el anillo tricúspide nativo. 2. Primera salida y segundo punto de entrada del anillo. 3. Segunda y tercera entrada del anillo. " src="358v19n04-90187909fig2.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figura 2. </span>1. Primer punto de entrada del anillo en el anillo tricúspide nativo. 2. Primera salida y segundo punto de entrada del anillo. 3. Segunda y tercera entrada del anillo. </span></p><p class="elsevierStylePara"> Normalmente, la inserción se completa tan solo con tres puntos. El anillo tricúspide biodegradable está disponible en tamaños pediátrico y adulto desde 16 a 36, igual que la versión mitral. El anillo biodegradable es especialmente ventajoso en la población pediátrica, ya que preserva la capacidad de crecimiento del anillo nativo y asegura un soporte duradero en posición tricúspide tal y como fue documentado por Mrowczynski, et al.<span class="elsevierStyleSup">12</span>.</p><p class="elsevierStylePara"> Se han publicado los resultados tempranos y a medio plazo de la anuloplastia tricúspide con anillo biodegradable comparados con los de la anuloplastia de De Vega<span class="elsevierStyleSup">13,14</span>. El componente no degradable de la porción central del anillo evita la redilatación del anillo tricúspide al proporcionar una resistencia permanente frente a la distensión, jugando un papel esencial en la baja tasa de recurrencia de IT a lo largo del tiempo, como documentaron Basel, et al.<span class="elsevierStyleSup">14</span> y como apreciamos en nuestra experiencia no publicada. La flexibilidad tridimensional del anillo permite un implante rápido y sencillo, incluso por medio de cirugía mínimamente invasiva toracoscópica y robótica, como fue confirmado por Panos, et al. en una experiencia preliminar<span class="elsevierStyleSup">15</span>.</p><p class="elsevierStylePara"> La estructura biodegradable del anillo disminuye el riesgo potencial de infección<span class="elsevierStyleSup">15</span> en comparación con los anillos convencionales que contienen material sintético. El anillo biodegradable también elimina la necesidad de anticoagulación profiláctica, ya que su posición intraanular previene la interacción «sangre-material biodegradable»<span class="elsevierStyleSup">16</span>.</p><p class="elsevierStylePara"> Debido a las características ventajosas mencionadas anteriormente, el anillo biodegradable es una elección idónea para la anuloplastia tricúspide, al proporcionar un remodelado anular más fisiológico y duradero con la inducción de tejido fibroso antólogo.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">AGRADECIMIENTOS</span></p><p class="elsevierStylePara"> Me gustaría agradecer sinceramente a Dominique Vala su valiosa asistencia editorial.</p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Tricuspid Annuloplasty Using a Biodegradable Ring </span></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">TRICUSPID ANNULOPLASTY USING A BIODEGRABLE RING</span></p><p class="elsevierStylePara"> The concept of a biodegradable ring is not a recent one. In 1983, Professor A. Carpentier predicted the potential use of biodegradable material for mitral annuloplasty<span class="elsevierStyleSup">1</span> and, in 1990, his team carried out experimental mitral valve repair with a polydioxanone absorbable ring, similar in shape to the rigid Carpentier-Edwards ring<span class="elsevierStyleSup">2</span>. In 1992, Duran described histological findings in an experimental study on sheep with De Vega tricuspid annuloplasty using a 2-0 polydioxanone suture. This suture material allowed the native tricuspid annulus to remain intact during the first three months and conserved its initial dimensions at five months by partial ring degradation<span class="elsevierStyleSup">3</span>. The idea of temporarily reinforcing the tricuspid annulus using biodegradable suture material was later corroborated by Duran, et al. in a clinical study carried out in 73 patients with functional tricuspid regurgitation and low pulmonary resistance; the low rate of recurrent tricuspid insufficiency over the follow-up period of two years reflected postoperative stability of the tricuspid annuloplasty<span class="elsevierStyleSup">4</span>.</p><p class="elsevierStylePara"> Although Carrier, et al. reported similar low failure rates and good long-term survival, be it with De Vega, Bex flexible linear reducer, or Carpentier-Edwards ring annuloplasties<span class="elsevierStyleSup">5</span>, many clinical studies have obtained superior repair durability and long-term survival using a ring, as compared with De Vega annuloplasty or suture bicuspidization of the tricuspid valve<span class="elsevierStyleSup">6-9</span>.</p><p class="elsevierStylePara"> In an experimental study on chronic tricuspid regurgitation comparing the use of a totally flexible polytetrafluoroethylene (PTFE) ring, an elastic silicone ring, a rigid metal ring and no ring at all, patterns of annular motion were similar to that of a normal annulus with PTFE and silicone rings; however, only the PTFE ring respected the natural undulation of the native annulus, while the other two rings forced the tridimensional annular plane to become horizontal<span class="elsevierStyleSup">10</span>.</p><p class="elsevierStylePara"> The biodegradable ring was conceived and developed with the aim of preserving dynamic tridimensional geometry of the tricuspid as well as of the mitral annulus.</p><p class="elsevierStylePara"> The tricuspid version of the Kalangos<span class="elsevierStyleSup">®</span> biodegradable ring is comprised of a poly-1,4-dioxanone polymer, set around a 2-0 polyvinyl monofilament in continuity over the entire portion of the ring and equipped with a stainless steel needle at each extremity (Fig. 1).</p><p class="elsevierStylePara"> The specific molecular weight of the biodegradable material ensures tridimensional flexibility and structural memory against subsequent deformity. The gradual degradation of the biodegradable material generates fibrous tissue, resulting in secondary autologous annular remodeling. Contrary to conventional rings, the biodegradable ring is implanted into the native annulus to promote inflammation and secondary transformation into fibrous tissue.</p><p class="elsevierStylePara"> The intra-annular insertion of the ring prevents release of degraded particles into the cardiac cavities. For tricuspid annuloplasty, biodegradable ring implantation starts at the level of the postero-septal commissure (2-3 mm from the insertion of the leaflet on the annulus and 2-3 mm in depth) (Fig. 2.1), moving the needle forward into the annulus and up through the first exit point (Fig. 2.2). By reinserting the needle through the exit point and pulling up the suture material, the ring is thus advanced up to the antero-septal commissure and completely inserted into the native annulus, and fixed by tying each of the two suture extensions at the level of the antero-septal and postero-septal commissures, respectively (Fig. 2.3)<span class="elsevierStyleSup">11</span>.</p><p class="elsevierStylePara"> Insertion is usually completed after only three stitches. The tricuspid biodegradable ring is available in pediatric and adult sizes ranging from 16 to 36, just like the mitral version. The biodegradable ring is especially advantageous in the pediatric population as it preserves the growth potential of the native annulus and ensures durable support in the tricuspid position, as reported by Mrowczynski, et al.<span class="elsevierStyleSup">12</span>.</p><p class="elsevierStylePara"> Early and midterm results for tricuspid annuloplasty using the biodegradable ring have been published in comparison with the De Vega annuloplasty<span class="elsevierStyleSup">13,14</span>. The non-degradable component of the central portion of the ring prevents re-dilatation of the tricuspid annulus by providing permanent resistance against tensile stretch, thus playing an essential role in the low rate of recurrent tricuspid insufficiency over time, as reported by Basel, et al.<span class="elsevierStyleSup">14</span> and as observed in our unpublished experience. The tridimensional flexibility of the ring allows for quick and easy implantation, even in minimally invasive thoracoscopic and robotic surgery, as confirmed by Panos, et al. in a preliminary experience<span class="elsevierStyleSup">15</span>.</p><p class="elsevierStylePara"> The biodegradable structure of the ring potentially decreases the risk of infection<span class="elsevierStyleSup">15</span> as opposed to conventional rings which contain synthetic material. The biodegradable ring also eliminates the need for prophylactic anticoagulation as its intra-annular position prevents all "blood-biodegradable material" interaction<span class="elsevierStyleSup">16</span>.</p><p class="elsevierStylePara"> Because of the advantageous characteristics mentioned above, the biodegradable ring is an optimal choice for tricuspid annuloplasty, providing for more physiological and durable annular remodeling with the induction of autologous fibrous tissue.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ACKNOWIEDGEMENT</span></p><p class="elsevierStylePara"> I would like to sincerely thank Dr. Dominique Vala for her invaluable editorial assistance.</p><hr></hr><p class="elsevierStylePara"> Correspondencia:<br></br> Afksendiyos Kalangos<br></br> Professor and Chairman <br></br> Division of Cardiovascular Surgery Hospital Universitario de Ginebra Medical School<br></br> Universidad de Ginebra Micheli-du-Crest, 24<br></br> CH-1211 Genève, Suiza<br></br> E-mail: <a href="mailto:Afksendyios.Kalangos@hcuge.ch" class="elsevierStyleCrossRefs">Afksendyios.Kalangos@hcuge.ch</a></p><p class="elsevierStylePara"> Recibido: 30 de septiembre de 2012 <br></br> Aceptado: 5 de octubre de 2012</p>" "pdfFichero" => "358v19n04a90187909pdf001.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "358v19n04-90187909fig1.jpg" "Alto" => 454 "Ancho" => 1020 "Tamanyo" => 41265 ] ] "descripcion" => array:1 [ "es" => "El anillo tricúspide biodegradable." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "358v19n04-90187909fig2.jpg" "Alto" => 404 "Ancho" => 929 "Tamanyo" => 47674 ] ] "descripcion" => array:1 [ "es" => "1. Primer punto de entrada del anillo en el anillo tricúspide nativo. 2. Primera salida y segundo punto de entrada del anillo. 3. Segunda y tercera entrada del anillo." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Cardiac valve surgery -the French correction." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Carpentier A." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg. 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Anuloplastia tricúspide con anillo biodegradable
Tricuspid Annuloplasty Using a Biodegradable Ring
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