El doctor Luis Nombela Franco es cardiólogo intervencionista y coordinador de intervencionismo de la cardiopatía estructural en el hospital Clínico San Carlos de Madrid
A pesar de que las patologías cardiacas siempre asustan, lo cierto es que las valvulopatías leves o moderadas no requieren tratamiento (eso sí, deben ser controladas periódicamente) y, para los casos graves, las técnicas percutáneas están dando más que excelentes resultados. Como muestra un botón: el campeón del mundo de triatlón Javier Gómez Noya y el también campeón del mundo de cuadriatlón Enrique Peces sufren sendas valvulopatía congénitas, pero este hecho nos les ha impedido seguir compitiendo y cosechar títulos.
Nos llama la atención el hecho de que se puedan realizar deportes de alta intensidad e incluso competir a nivel profesional con una cardiopatía de este tipo… ¿No se desaconseja la práctica de ejercicio físico a los pacientes?
La valvulopatía más frecuente se va adquiriendo con la edad. Así, la mayor parte de los pacientes que sufre esta enfermedad nace con unas válvulas estructuralmente normales pero que, con el paso de los años van degenerándose y provocan la enfermedad.
Pero hay otras valvulopatías que son congénitas, es decir, tienen una afectación desde el nacimiento y estas son más propensas a que degeneren conforme pasa el tiempo. Pero si la válvula es funcionalmente normal no impide la realización de un deporte. En principio las personas que padecen una valvulopatía pueden realizar cualquier tipo de ejercicio dependiendo de las posibilidades y de las limitaciones de cada persona, pero no hay ningún tipo de contraindicación. Sí es necesario que la persona que tenga una valvulopatía congénita sea seguido por un cardiólogo y debe realizarse unas pruebas de imagen (un ecocardiograma básicamente) para detectar si existe o no un funcionamiento anormal de esta válvula. Si funciona con normalidad, no se contraindica la realización de deportes.
En el terreno de las valvulopatías, hasta hace una década el único tratamiento posible era la cirugía a corazón abierto. Pero la llegada de una nueva técnica, el transcatéter de la válvula aórtica (TAVI), ha revolucionado este panorama. ¿Puede explicarlos en qué consiste?
Hasta hace unos 10 o 14 años el único tratamiento de las valvulopatías severas era realizar una cirugía a corazón abierto, pero ahora han surgido técnicas, llamadas percutáneas, que son mínimamente invasivas, que se realizan a través de las venas y las arterias de la ingle (arterias femorales) y que nos permiten acceder a través de los vasos sanguíneos a las válvulas del corazón e implantar una nueva válvula o corregir la enfermedad. En concreto la TAVI es un procedimiento que en mi hospital llevamos practicando desde el año 2007, y se han realizado muchísimas intervenciones ya de este tipo es nuestro país y en todo el mundo. Se realiza cuando la válvula aórtica se obstruye y estrecha e impide el flujo de sangre adecuado desde el corazón izquierdo hacia la arteria aorta que es la que proporciona sangre a todo el organismo, a todos los órganos. La técnica Tavi consiste en avanzar una prótesis aórtica a través de una arteria de la ingle de forma que llegue hasta la válvula aórtica estrechada y colocar una válvula nueva dentro del interior de la válvula afectada.
¿Qué ventajas ofrece esta nueva técnica?
Es un procedimiento que se realiza en aproximadamente una hora, frecuentemente sin necesidad de anestesia general y el paciente suele tener una recuperación muy rápida: en muchos casos con una estancia de menos de un día en cuidados intensivos y después de 2 o 3 días puede marcharse a casa.
Cuando la valvulopatía es de grado severo, él único tratamiento que existe es, o bien la cirugía o bien las técnicas percutáneas
En el reciente congreso de la American College of Cardiology (ACC) en Nueva Orleans se han presentado dos estudios que suponen un cambio en el paradigma actual de tratamiento de los pacientes con estenosis aórtica, son el PARTNER 3 y el Evolut Low Risk Trial, ambos publicados en The New England Journal of Medicine. ¿Qué nos dicen estos estudios?
Esta técnica lleva ya muchos años implantada y ha ido revolucionando el tratamiento de la estenosis aórtica (la obstrucción de esta válvula que comunica el corazón con el resto del organismo). Desde el año 2010, fecha en que se publicó el primer estudio hasta ahora se han ido analizando diferentes perfiles de pacientes. Inicialmente se estudió esta técnica en pacientes que no se podían operar por padecer alguna otra enfermedad, luego en aquellos con un alto riesgo quirúrgico determinado por unos scores y, posteriormente, con riesgo intermedio. Ahora, este último estudio, el PARTNER 3 y también el Evolut Low Risk Trial, han comparado la técnica TAVI con la cirugía en pacientes de bajo riesgo con estenosis aórtica aislada. Lo que han demostrado estos estudios es que a un año de seguimiento los pacientes a los que se les realiza la TAVI tienen menor mortalidad, menor ictus y menor tasa de reingreso, comparado con los pacientes a los que se les realiza una cirugía cardiaca.
La valvulopatía cardíaca está provocada por el desgaste o daño de una o más válvulas, lo que afecta al flujo sanguíneo del corazón, ¿cuáles son las más frecuentes y cómo se tratan?
Las valvulopatías son aquellas enfermedades que afectan a las válvulas cardiacas. En el corazón hay 4 válvulas: la aortica y la mitral en el corazón izquierdo y la válvula tricúspide y la pulmonar en el corazón derecho. La valvulopatía más frecuente en la población general es la insuficiencia mitral, un fallo en el cierre de la válvula mitral, pero esta valvulopatía se interviene menos que la aortica. En este caso la valvulopatía más frecuente es la estenosis y es la que más se trata de forma invasiva.
Cuando la valvulopatía es de grado severo, él único tratamiento que existe es, o bien la cirugía o bien estas técnicas mínimamente invasivas de las que hemos hablado, no existe ningún tratamiento médico capaz de revertir esa situación. La única solución es sustituir esa válvula o repararla. El tratamiento farmacológico para estas es meramente paliativo o sintomático, no corrige la valvulopatía. Se pueden controlar en cierto modo los síntomas, pero nada más.
Las valvulopatías leves o moderadas sólo requieren ser controladas por el cardiólogo para que, en el momento en el que aparezcan los síntomas y se hagan de grado severo, poder intervenir y corregirlas.
En cuanto a tratamiento percutáneo mínimamente invasivo, el más avanzado y el que está más establecido es el de la aórtica. Existen también otros tratamientos para la válvula mitral para la tricúspide y para la pulmonar. Es verdad que no están tan evolucionados, pero se están realizando muchos estudios y avanzando en estas técnicas percutáneas.
¿Qué síntomas presenta esta patología? ¿Qué nos debe llevar a acudir sin demora al especialista?
El síntoma principal es la disnea, la falta de aire al realizar un esfuerzo, aunque en algunos pacientes en estadios más avanzados, también aparece en reposo. La valvulopatía provoca una insuficiencia del ventrículo, hay una acumulación de líquido en los pulmones, y esto provoca esa falta de aire. Otros síntomas como la pérdida de conocimiento o dolor de pecho, la angina de pecho, también nos pueden alertar sobre la existencia de valvulopatías.
La incidencia aumenta con la edad, ¿no es así?
La mayor parte de ellas son degenerativas, aunque se pueden asociar también a otras enfermedades, y aumentan con la edad. La prevalencia por tanto es más frecuente en pacientes octogenarios que en pacientes más jóvenes.
Son tristemente conocidos varios casos de muerte súbita en deportistas, ¿por qué se produce una muerte súbita? ¿Puede una valvulopatía provocarla?
Las causas de muerte súbita son variadas, la más frecuente es un problema coronario, un infarto del corazón. También pueden existir arritmias, pueden provocar una muerte súbita los trastornos eléctricos en el corazón y, efectivamente, la valvulopatía aortica también puede debutar, cuando hay ese estrechamiento tan severo del flujo de sangre, con muerte súbita. Pero nos todas las muertes súbitas se deben a valvulopatías.
A su entender y generalizando, ¿los grandes enemigos del corazón son adquiridos (y por tanto modificables) o nos vienen de serie?
Adquiridos. El mayor enemigo del corazón agrupa los factores de riesgo cardiovascular: el tabaco, la diabetes, la hipertensión, el colesterol, el sedentarismo y la falta de ejercicio… Todos estos son factores de riesgo que desencadenan no solo enfermedades en el corazón sino también en el riñón, en los vasos cerebrales… Efectivamente también hay enfermedades congénitas del corazón, pero a nivel general provocan más enfermedad los antes citados.
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