Introdução
A indicação da intervenção cirúrgica ou percutânea no paciente com doença valvar está atrelada ao preciso diagnóstico anatômico e funcional, além do conhecimento da história natural da doença.
Nesta atualização da Diretriz Brasileira de Valvopatias de 2011, são contemplados apenas pacientes com valvopatia anatomicamente importante (estágios C e D da Diretriz da American College of Cardiology (ACC)/ American Heart Association (AHA), de 2014). As tabelas e fluxogramas que aqui constam demonstram passos sequenciais que norteiam o diagnóstico anatômico, etiológico e funcional, definindo a conduta alinhada às melhores práticas, com uso racional de recursos.
A avaliação clínica continua absolutamente fundamental, destacando-se a grande especificidade do exame físico para o diagnóstico anatômico e a anamnese como principais recursos para avaliação funcional e indicação para intervenção.
Além da proposta dos passos, esta Diretriz indica, para efeito de comparação, as recomendações das duas principais diretrizes internacionais - ACC/AHA 2017 e European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) 2017.
Vale ressaltar que a profilaxia de febre reumática, profilaxia da endocardite infecciosa, assim como indicações de intervenção na valvopatia pulmonar, mantém exatamente os mesmos princípios, conforme publicado na Diretriz brasileira de 2011 e descrito a seguir:
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Primeiro passo: certificar-se de que a valvopatia é anatomicamente importante;
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Segundo passo: avaliar a etiologia, incluindo história clínica e antecedentes pessoais, em conjunção com exames complementares;
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Terceiro passo: avaliar os sintomas - uma vez definida a valvopatia anatomicamente importante, a avaliação dos sintomas secundários é fundamental na decisão de intervenção. O tratamento farmacológico está indicado para alívio dos sintomas até o tratamento intervencionista da doença valvar;
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Quarto passo: avaliação de complicadores - na ausência de sintomas, a identificação de complicadores anatômicos e/ou funcionais (especialmente hipertensão pulmonar, remodelamento ventricular, disfunção sistólica, dilatação aneurismática de aorta, fibrilação atrial) pode ser determinante para intervenção nos pacientes assintomáticos;
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Quinto passo: tipo de intervenção - o procedimento de correção da doença valvar pode ser cirúrgico ou transcateter, com indicação individualizada dependendo do risco operatório, das comorbidades e da decisão do Heart Team.
Heart Team
O Heart Team é um conceito no qual um conjunto de diferentes profissionais com experiência em doenças valvares compartilha a decisão sobre o melhor tratamento para um determinado paciente. Com a introdução de diferentes tipos de abordagem para o tratamento de pacientes com valvopatias, o Heart Team tem sido cada vez mais utilizado em seu manejo. É composto por diversas subespecialidades cardiológicas, com especialistas que exercem papéis diferentes e fundamentais em cada passo do cuidado: do cardiologista clínico (a quem cabe a seleção e a indicação de pacientes, além do acompanhamento pré e pós-intervenção), ao cirurgião cardíaco e ao hemodinamicista, responsáveis pela concretização dos procedimentos indicados pelo Heart Team. Além deles, o radiologista é importante na análise de dados para avaliar a possibilidade técnica de realização de cada tipo de intervenção; e o ecocardiografista, além de avaliar os dados pré-operatórios, pode também acompanhar o procedimento, colaborando para um melhor resultado.
Estenose mitral
Enquanto no Brasil e demais países em desenvolvimento a principal causa da estenose mitral (EM) é a febre reumática, nos países desenvolvidos observa-se aumento da incidência de EM degenerativa, associada à calcificação do anel mitral e que se desenvolve em pacientes idosos.
Nesta Diretriz, a EM é classificada como anatomicamente importante quando a área valvar mitral for menor do que 1,5 cm2.
Para os pacientes reumáticos, a valvuloplastia mitral por cateter-balão (VMCB) continua sendo o tratamento de escolha, seguido pela cirurgia valvar.
No caso dos pacientes com EM degenerativa, o tratamento inicial de quem se apresenta sintomático é farmacológico, reservando-se intervenção para casos refratários. Nos pacientes com alto risco cirúrgico, o implante valvar mitral transcateter foi, até o momento, realizado em um número limitado de casos. Para a sua ampla indicação e realização, ainda são requeridos estudos que validem os seus resultados em maior escala.
Algoritmo para avaliação da estenose mitral importante. CF: classe funcional; FA: fibrilação atrial; VMBC: valvuloplastia mitral por cateter-balão.
Insuficiência mitral primária crônica
A insuficiência mitral (IM) primária crônica é uma das valvopatias mais prevalentes mundialmente. A etiologia reumática ainda é predominante no Brasil, embora o prolapso da valva mitral tenha aumentado em frequência. Diferentemente das Diretrizes europeia e americana, dividimos as indicações de tratamento cirúrgico com base na etiologia reumática e não reumática. A plástica valvar mitral é o tratamento cirúrgico preferencial nos casos com anatomia favorável. Os pacientes de etiologia reumática têm menos probabilidade de plástica valvar com bons resultados, sendo necessária a troca valvar, na maioria dos casos.
Algoritmo para avaliação da insuficiência mitral primária importante. CF: classe funcional; FE: fração de ejeção; DSVE: diâmetro sistólico de ventrículo esquerdo; PSAS: pressão sistólica da artéria pulmonar; FA: fibrilação atrial.
Insuficiência mitral secundária
A IM crônica secundária, ou funcional, deve-se a alterações na geometria ventricular, resultando em má coaptação das cúspides valvares e aparecimento de refluxo valvar. Habitualmente é causada por doença isquêmica cardíaca ou por outras cardiopatias dilatadas, de diversas etiologias. As indicações de tratamento são distintas da IM primária, uma vez que o problema básico não está nas cúspides valvares. A indicação de intervenção na IM secundária deve ser restrita a casos refratários ao tratamento clínico convencional.
Estenose aórtica
A estenose aórtica (EAo) apresenta prevalência crescente na atualidade em razão do aumento da expectativa de vida e do consequente envelhecimento da população. Atualmente, a causa mais comum de EAo é a calcificação aórtica, que acomete principalmente pacientes idosos. O tratamento transcateter tornou-se uma opção à troca valvar cirúrgica em casos selecionados após avaliação cuidadosa da expectativa de vida, do grau de fragilidade e da anatomia valvar aórtica.
Algoritmo para avaliação da estenose aórtica importante. FE: fração de ejeção; TE: teste ergométrico; TAVI: implante de bioprótese aórtica transcateter (da sigla em inglês, transcatheter aortic valve implantation).
Algoritmo para avaliação da estenose aórtica baixo-fluxo e baixo-gradiente com fração de ejeção reduzida. FE: fração de ejeção.
Algoritmo para avaliação da estenose aórtica paradoxal. AVA: área valvar aórtica; FE: fração de ejeção; TAVI: implante de bioprótese aórtica transcateter (da sigla em inglês, transcatheter aortic valve implantation).
Insuficiência aórtica crônica
A insuficiência aórtica (IAo) crônica pode decorrer de alterações das cúspides valvares e/ou alterações do ânulo da valva aórtica. Destacamos a manutenção do tratamento clínico em pacientes reumáticos assintomáticos e com função ventricular normal que apresentam dilatação ventricular.
Algoritmo para avaliação da insuficiência aórtica importante. FE: fração de ejeção; DDVE: diâmetro diastólico de ventrículo esquerdo; DSVE: diâmetro sistólico de ventrículo esquerdo; TAVI: implante de bioprótese aórtica transcateter (da sigla em inglês, transcatheter aortic valve implantation).
Insuficiência tricúspide importante
A maioria dos casos de insuficiência tricúspide (IT) é funcional/secundária e ocorre pela dilatação progressiva do anel valvar tricúspide. Dentre as causas primárias, destacamos a febre reumática. A correção de valvopatias do lado esquerdo do coração não necessariamente corrige a IT ou impede a sua progressão, principalmente quando o anel valvar é maior do que 40 mm e/ou a regurgitação é de moderada a importante. Nos casos de IT secundária e isolada, o tratamento medicamentoso é preferível e a cirurgia deve ser indicada em casos refratários.
Estenose tricúspide
A estenose tricúspide (ET) é uma complicação infrequente da cardiopatia reumática; quando presente, está associada à doença mitral da mesma etiologia. O tratamento medicamentoso deve ser instituído no paciente sintomático enquanto aguarda procedimento cirúrgico.
Anticoagulação em valvopatia
Desde as Diretrizes Brasileiras de Valvopatias de 2011, foram publicados dados embasando o uso dos novos anticoagulantes orais (NOACs), inibidores diretos da trombina ou antifator X, em pacientes valvopatas.
Devido ao alto risco de fenômenos embólicos, esses pacientes continuam a apresentar indicação de anticoagulação em diversas situações clínicas. A varfarina segue sendo a principal medicação a ser utilizada. Com relação aos NOACs, é importante ressaltar que não houve trabalhos delineados especificamente para essa população que demonstraram benefício do seu uso para valvopatas. Assim, mantém-se a contraindicação à sua utilização nos grupos de maior risco: EM reumática e prótese mecânica.
Também não se recomenda a aplicação do escore CHA2DS2-VASc em pacientes com valvopatia anatomicamente importante; isso porque essa avaliação subestima o risco em pacientes com escore ≤ 1.
Doença multivalvar
Consideramos doença multivalvar o acometimento primário de duas ou mais valvas. Portanto, são excluídas dessa classificação valvopatias consequentes à valvopatia primária, como é o caso da IT funcional, consequente à doença mitral.
No Brasil, a doença multivalvar é resultado do acometimento reumático na maioria das vezes. Em idosos, pode acontecer quando há extensa calcificação do aparelho mitral acompanhando doença valvar aórtica degenerativa.
Disfunção de prótese valvar
Após cirurgia de troca valvar, os seguimentos clínico e ecocardiográfico periódicos devem ser realizados para a detecção precoce de disfunção de prótese, assim como para a identificação de sintomas e complicadores anatômicos e funcionais secundários.
Novos procedimentos, como tratamento percutâneo de regurgitação paravalvar e valve-in-valve, já são realidade e estão incluídos nas novas Diretrizes.
Trombose de prótese valvar
A trombose de prótese valvar é evento incomum, sendo mais frequente em próteses mecânicas, principalmente em posição mitral, e cursa com alta morbimortalidade. A manifestação clássica é a insuficiência cardíaca aguda/exacerbada em paciente com anticoagulação ineficaz. As recomendações das Diretrizes internacionais são distintas em relação à conduta e há carência de estudos randomizados. Recentemente, há tendência de priorização da trombólise frente à cirurgia, com base em dados de metanálise fornecidos por 48 estudos. Em geral, procedimento cirúrgico é indicado em casos de trombose de prótese em câmaras esquerdas, com grave repercussão clínica e alto risco de sangramento.
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Nota: estas Diretrizes se prestam a informar e não a substituir o julgamento clínico do médico que, em última análise, deve determinar o tratamento apropriado para seus pacientes.
Referências
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Datas de Publicação
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Publicação nesta coleção
2017