{"id":117579,"date":"2015-05-06T00:00:00","date_gmt":"2015-05-06T00:00:00","guid":{"rendered":""},"modified":"2015-05-06T00:00:00","modified_gmt":"2015-05-06T00:00:00","slug":"evaluacion-de-la-cirugia-valvular-mitral-mediante-cirugia-minimamente-invasiva-por-toracotomia-frente-a-esternotomia-media-estudio-de-eficacia-seguridad-y-costes-ajustado-por-nivelacion-del-riesgo","status":"publish","type":"post","link":"https:\/\/www.deberes.net\/tesis\/anestesiologia-quirurgica\/evaluacion-de-la-cirugia-valvular-mitral-mediante-cirugia-minimamente-invasiva-por-toracotomia-frente-a-esternotomia-media-estudio-de-eficacia-seguridad-y-costes-ajustado-por-nivelacion-del-riesgo\/","title":{"rendered":"Evaluacion de la cirugia valvular mitral mediante cirugia minimamente invasiva por toracotomia frente a esternotomia media: estudio de eficacia, seguridad y costes ajustado por nivelacion del riesgo"},"content":{"rendered":"<h2>Tesis doctoral de <strong> Paula Isabel Carmona Garcia <\/strong><\/h2>\n<p>Objetivos la cirug\u00eda cardiaca m\u00ednimamente invasiva (cmiv) representa un cambio significativo y paradigm\u00e1tico en la cirug\u00eda cardiaca. Incluye una constelaci\u00f3n de t\u00e9cnicas que intentan minimizar el trauma quir\u00fargico a trav\u00e9s de incisiones peque\u00f1as tor\u00e1cicas. Es necesario una revisi\u00f3n de nuestros resultados para definir si las propuestas ventajas de esta t\u00e9cnica  (procedimiento menos doloroso, recuperaci\u00f3n m\u00e1s precoz, menor sangrado postoperatorio, menor n\u00famero de transfusiones, menor gasto sanitario) son reproducidas en nuestro medio.  el presente estudio est\u00e1 basado en la hip\u00f3tesis de que la cmiv por minitoracotom\u00eda no es inferior en t\u00e9rminos de morbimortalidad perioperatoria, seguridad y eficacia a corto y medio plazo cuando se compara con la cirug\u00eda convencional v\u00eda esternotom\u00eda media (em).  m\u00e9todos\t       se recogieron de manera retrospectiva los datos de una serie de pacientes sometidos a cirug\u00eda mitral que recibieron recambio valvular o reparaci\u00f3n (asociado o no a reparaci\u00f3n tricusp\u00eddea) en un s\u00f3lo centro (consorcio hospital general universitario de Valencia, espa\u00f1a) entre 2009-2013. Las cohortes recogidas incluyeron 44 casos de cmiv y 168 cirug\u00edas mitrales mediante em.  \tse realiz\u00f3 un emparejamiento estad\u00edstico por t\u00e9cnicas de regresi\u00f3n log\u00edstica y nivelaci\u00f3n del grado de propensi\u00f3n considerando las principales variables de riesgo perioperatorio y comorbilidad para identificar 44 controles dentro del grupo de em frente a los 44 casos del grupo de cmiv.  Se realiz\u00f3 un an\u00e1lisis estad\u00edstico entre los casos y los controles emparejados para variables descriptivas, mortalidad y morbilidad mayor perioperatoria, variables de eficacia y seguridad, requerimientos transfusionales, duraci\u00f3n de estancias hospitalarias y gastos econ\u00f3micos derivados de ambas t\u00e9cnicas. Se realiz\u00f3 asimismo un an\u00e1lisis univariante y multivariante para un evento compuesto de morbilidad mayor, eficacia, seguridad y requerimientos de hemoderivados para la detecci\u00f3n de predictores independientes y un an\u00e1lisis de supervivencia y calidad de la reparaci\u00f3n o recambio valvular a largo plazo. resultados no se hallaron diferencias relevantes en relaci\u00f3n a variables preoperatorias o comorbilidades as\u00ed como en la morbi-mortalidad perioperatoria ni en la calidad de la reparaci\u00f3n a largo plazo. El seguimiento medio fue de 26,6\u00c2\u00b114,6 meses para el grupo de cmiv y 28,4\u00c2\u00b11,1  meses para la em, p=0,63.   \tno observamos diferencias estad\u00edsticamente significativas en el evento compuesto de morbilidad mayor (0 frente 6,8%, p=0,25), seguridad (6,8% frente 4,5%, p=1) y eficacia (9,1 frente 11,4%, p=1) entre la cmiv frente em respectivamente. La reoperaci\u00f3n por sangrado (6,8% frente 0%, p=0,08) y la incidencia de neumot\u00f3rax y derrames pleurales  que requirieron drenaje (11,4% frente 0%, p=0,05) tuvo una incidencia mayor en el grupo de cmiv. El n\u00famero de pacientes que requirieron transfusi\u00f3n fue significativamente m\u00e1s baja en el grupo de cmiv frente em (38% frente 59%, p=0,01). El n\u00famero de concentrados de hemat\u00edes (0(0-9) frente 1(0-7), p=0,03) y plasma fresco congelado (0(0-3) frente 0(0-5), p=0,01)  fue significativamente menor en el grupo de cmiv. El n\u00famero de plaquetas (0(0-1) frente 0(0-2), p=0,35) sin embargo no fue estad\u00edsticamente diferente entre grupos. La cmiv constituy\u00f3 un factor protector independiente para la transfusi\u00f3n de hemoderivados en el an\u00e1lisis uni y multivariante.  las estancias en uci 2,1\u00c2\u00b10,9 frente 2,8\u00c2\u00b11,2 (p=0,001) y hospitalaria 6\u00c2\u00b13,4 vs 7,2\u00c2\u00b12,9 (p=0,08) fueron m\u00e1s cortas en el grupo cmiv. La supervivencia libre de enfermedad o disfunci\u00f3n valvular m\u00e1s que moderada result\u00f3 del 93% en el grupo cmiv frente al 88,4% (p=0,5).  El gasto medio por procedimiento de cmiv fue de 5434,31\u00c2\u00bf frente a 6353,96\u00c2\u00bf para la em. discusi\u00f3n a pesar de los resultados prometedores de las grandes instituciones con gran volumen de pacientes, la adopci\u00f3n de las t\u00e9cnicas de cmiv aplicadas a la reparaci\u00f3n o recambio de v\u00e1lvula mitral no ha sido uniforme en los centros de nuestro medio por la limitada exposici\u00f3n de la v\u00e1lvula, las potenciales lesiones arteriales y las dificultades en la deaireaci\u00f3n del coraz\u00f3n que pueden resultar en un incremento  de los accidentes c\u00e9rebrovasculares y la morbilidad global.  nuestros resultados muestran que la cmiv se asocia a una menor proporci\u00f3n de pacientes transfundidos, menor transfusi\u00f3n de hemoderivados, menores estancias en uci y a una disminuci\u00f3n de los costes por intervenci\u00f3n, sin que esto se asocie a una mayor morbimortalidad perioperatoria ni a un impacto negativo en la seguridad ni en la durabilidad de la reparaci\u00f3n o del recambio valvular.   abstract  objectives minimally invasive cardiac surgery (cmiv) represents a significant paradigm shift in cardiac surgery. A comprehensive review of our results is necessary to determine whether the proposed advantages of this technique (less painful procedure, earlier recovery, less postoperative bleeding, fewer transfusions, lower health care costs and less morbidity) are reproducible in our environment. the present study is based on the hypothesis that cmiv by anterior thoracotomy is not inferior in terms of perioperative morbidity and mortality, safety and efficacy in short and medium term when compared with conventional surgery via median sternotomy (ms). methods        data from a consecutive series of patients undergoing mitral valve repair or replacement surgery in a single center (consorcio general hospital universitario de Valencia, spain) between 2009-2013 was collected retrospectively. The cohorts included 44 cases of mitral cmiv and 168 surgeries by ms. a statistical matching propensity score test was performed including the main perioperative risk  variables to identify 44 controls within the ms group versus 44 cases in the cmiv group. Statistical analysis between cases and controls matched for descriptive variables, perioperative mortality and morbidity, efficacy and safety variables, transfusion requirements, length of hospital stays and economical costs arising from both techniques were performed. Univariate and multivariate analysis for a composite endpoint of morbidity, efficacy, safety and requirements of blood products was performed to detect independent predictors. Analysis of survival and quality of repair in long term was also performed. results no significant differences were found regarding to preoperative variables and comorbidities as well as perioperative morbidity and mortality or quality of long-term repair between groups. Mean follow-up was 26.6 \u00c2\u00b1 14.6 months for the group and 28,4 \u00c2\u00b1 cmiv 1,1 months for ms, p = 0,63.   we observed no statistically significant differences in the composite event of morbidity (0 versus 6,8%, p = 0.25), security (6,8% vs. 4,5%, p = 1) and efficiency (9,1 versus 11,4%, p = 1) between cmiv and ms respectively. Reoperation for bleeding (6,8% vs 0%, p = 0,08) and the incidence of pneumothorax and pleural effusion requiring drainage (11,4% vs. 0%, p = 0,05) had a higher incidence in the cmiv group. The number of patients who required transfusion was significantly lower in the group cmiv (38% vs 59%, p = 0,01). The number of units of packed red blood cells (0 (0-9) vs 1 (0-7), p = 0,03) and fresh frozen plasma units (0 (0-3) vs 0 (0-5), p = 0,01) was significantly lower in the group cmiv. The number of platelets units (0 (0-1) vs 0 (0-2), p = 0.35) was not statistically different between groups. The cmiv was an independent protective factor for blood transfusion in the univariate and multivariate analysis. icu length of stay, 2,1 \u00c2\u00b1 0,9 vs 2,8 \u00c2\u00b1 1,2 (p = 0,001) and hospital length of stay, 6 \u00c2\u00b1 3,4 vs 7,2 \u00c2\u00b1 2,9 (p = 0,08) were shorter in the cmiv group. the cumulative survival was 93% in group cmiv vs 88,4% for the ms group with a disease-free survival or moderate valvular dysfunction overall of 90,7% (p=0,5). the average cost per procedure was 5434,31\u00c2\u00bf vs  6353,96 \u00c2\u00bffor cmiv and ms respectively. discussion despite the promising results of large institutions with large volume of patients, the adoption of cmiv techniques has not been uniform in centers in our country and to date, there are no national series reporting their results in cmiv. our results show that cmiv is associated with a lower proportion of transfused patients, less blood transfusion requirements, shorter length of stays in icu and reduced costs without increased perioperative morbidity and mortality nor a negative impact on safety or durability of repair or valve replacement.<\/p>\n<p>&nbsp;<\/p>\n<h3>Datos acad\u00e9micos de la tesis doctoral \u00ab<strong>Evaluacion de la cirugia valvular mitral mediante cirugia minimamente invasiva por toracotomia frente a esternotomia media: estudio de eficacia, seguridad y costes ajustado por nivelacion del riesgo<\/strong>\u00ab<\/h3>\n<ul>\n<li><strong>T\u00edtulo de la tesis:<\/strong>\u00a0 Evaluacion de la cirugia valvular mitral mediante cirugia minimamente invasiva por toracotomia frente a esternotomia media: estudio de eficacia, seguridad y costes ajustado por nivelacion del riesgo <\/li>\n<li><strong>Autor:<\/strong>\u00a0 Paula Isabel Carmona Garcia <\/li>\n<li><strong>Universidad:<\/strong>\u00a0 Murcia<\/li>\n<li><strong>Fecha de lectura de la tesis:<\/strong>\u00a0 05\/06\/2015<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3>Direcci\u00f3n y tribunal<\/h3>\n<ul>\n<li><strong>Director de la tesis<\/strong>\n<ul>\n<li>Alejandro Vazquez Sanchez<\/li>\n<\/ul>\n<\/li>\n<li><strong>Tribunal<\/strong>\n<ul>\n<li>Presidente del tribunal: Juan  bautista Martinez leon <\/li>\n<li>rosario Vicente guill\u00e9n (vocal)<\/li>\n<li>Francisco Guti\u00e9rrez Garc\u00eda (vocal)<\/li>\n<li> Arribas leal Jos\u00e9 Mar\u00eda (vocal)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Tesis doctoral de Paula Isabel Carmona Garcia Objetivos la cirug\u00eda cardiaca m\u00ednimamente invasiva (cmiv) representa un cambio significativo y paradigm\u00e1tico [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center 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