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Interventional cardiology bets on development: First minimal access percutaneous aortic valve implanted in Cuba

cardiología-580x322This time there is no “open heart” surgery. The multidisciplinary team that enters the surgical unit of the Institute of Cardiology and Cardiovascular Surgery (ICCC) around 10:30 am on October 31 knows the steps, has reviewed them with precision.

In severe cases of degenerative aortic stenosis—or what is the same, the narrowing of the valve in the large blood vessel that originates from the heart (aorta) and does not allow the valve to open completely, which reduces blood supply and makes it much harder for the heart to function—the option is to operate for the purpose of repairing or replacing the valve.

The heart of patients with this condition can weaken and cause chest pain, fatigue, and shortness of breath; and also, stop beating.

Dr. Leonardo López Ferrero, interventional cardiologist and head of the ICCC’s Cardiology and Hemodynamics service, knows this. He is in charge of the team of specialists who this Monday implanted the first minimal access percutaneous aortic valve in Cuba.

The procedure, novel in the country and performed on two patients, places Cuban interventional cardiology in a valuable line of development for the treatment and quality of life of people with this condition, and who cannot be beneficiaries of conventional surgery.

Why is it a beneficial procedure?

According to the specialized literature, degenerative aortic stenosis has an estimated prevalence of between 4% and 7% in the population over 65 years of age. Around 30% of cases do not undergo surgery, due to contraindications to surgical treatment and associated comorbidities. Meanwhile, the global mortality of patients with this condition is 50% to 60%, between the first two and three years after diagnosis, if no intervention is performed.

Through two femoral arteries and a radial artery, the entire minimally invasive procedure is performed, Dr. López Ferrero highlighted.

“Greater advantages for the patient’s recovery, a less aggressive approach, a shorter hospital stay and the possibility of returning more quickly to family and work life, are some of the benefits it offers,” he said.

The interventional cardiologist explained that the two valves that were implanted today are percutaneous, that is, they are transported in a catheter to the aortic valve, a catheter is taken to the narrow aortic valve and the new valve (from bovine pericardium) that is assembled over a stent replaces the patient without the need for open surgery.

For López Ferrero, introducing this new technique in interventional cardiology in the country has a great impact: “In Cuba, more than 30% of our population is already over 75 years old and this is a disease that appears in advanced ages of life,” he specified.

The donation of the devices by the European company Iberhospitex S.A. and coming from India, allowed this very expensive intervention to be carried out, the specialist pointed out.

“These valves are priced at around 20,000 euros and, if you add the necessary equipment and consumables, the cost can rise to 60,000 euros,” he said.

According to the expert, the placement of these devices is the first step for the gradual start of a transcatheter aortic valve implantation (TAVI) program, for which the ICCC is committed, although the institution has For many years, he has operated patients of this type and performed surgical replacement of the valve, by conventional approach.

It would benefit people who meet the established criteria (electrocardiographic, echocardiographic, angiographic and tomographic established and who have cardiac surgery contraindicated due to the high risk it entails).

Dr. Carmen Rosa Martínez Fernández, director of the Institute of Cardiology and Cardiovascular Surgery, stressed to the press that the medical act goes beyond performing a procedure, since it is part of a practical training workshop that follows the continuous training received by cardiologists center interventionists, and that can be extended to professionals from the rest of the country.

A multidisciplinary team made up of cardiologists from the Institute and the William Soler Cardiocenter, cardiovascular surgeons, sonographers, imaging specialists, anesthesiology specialists and nursing staff, were present at the intervention, which was accompanied by the Spanish doctor Ignacio Amat Santos, head of Hemodynamics and Interventional Cardiology at the University Clinical Hospital of Valladolid.

Martínez Fernández pointed out that Dr. López, head of the institute’s Cardiology and Hemodynamics service, has been trained in Barcelona hospitals on several occasions to perform this procedure. The presence here of Spanish teachers today is also part of a continuous process of training and collaboration.

“The Cuban population is aging and there is a degeneration of the aortic valve as a result of this demographic phenomenon,” said the specialist who insisted on the advantages of the patient’s quality of life.

“Relatives and patients have given informed consent for this to be done with a high degree of gratitude, convinced that it is a developmental step for the better,” she added.

This is also the opinion of Professor Pedro Nodal, head of Anesthesiology, Resuscitation and Surgical Unit of the ICCC and Dr. Luis Leonel Martínez Clavel, anesthesiologist in charge of the new procedure.

“This is the first time we are going to do it here. We chose general anesthesia as a protocol because it is the safest way for the patient and also for us to be able to provide that security. Despite the fact that other techniques are performed in the world, even with local anesthesia and sedation, we cannot run before crawling”, explains Martínez Clavel.

Professor Nodal ratifies it, all the support in surgery, anesthesiology, perfusionists in charge of operating the extracorporeal circulation machine is guaranteed to assume any eventuality.

The Spanish doctor Ignacio Amat Santos, head of Hemodynamics and Interventional Cardiology at the University Clinical Hospital of Valladolid, expresses his satisfaction “for carrying out, together with my colleagues from the Institute of Cardiology and Cardiovascular Surgery, the first minimally invasive aortic prosthesis implant interventions, without the need to open patients, only aided by a small catheter”, he said.

He explained that these valves were developed in the early 2000s. “Some patients had complications from such a major procedure as opening the chest to change a heart valve. So an attempt was made to develop something less aggressive, that the patient tolerated better, that they could go home earlier, that they would recover faster. And the implantation of a valve inside a stent was developed that folds and is inserted through a very fine tube from the groin to the heart, and then inside the diseased valve and correct its malfunction, ”he pointed out.

Amat Santos pointed out that, although the initial experiences were complex, enough experience has already been acquired to generalize its use little by little in the population “and we are working on developing this technique in Havana.”

In Spain, he said, between 4,000 and 5,000 procedures are performed annually in various hospitals. Some countries like Germany or the United States have carried out many interventions of this type and already number in the hundreds of thousands.

But, he added, it was only two years ago that research showed that in patients at low risk for open surgery that option was better. “This means that we have to try to generalize it to all patients who need an intervention of this type in the heart,” he pointed out.

On the socialization of science and medical advances, the Spanish expert believed that it is fundamental, while the entire learning curve that has taken place over the last two decades, since this therapy began with the first patients, is shared. the most complex.

Added to this is the importance of professionals being trained and specialized, “because technology is essential but skill is something that must be learned,” he said, and highlighted the link that has been established with Cuba in this regard.

“I am convinced that the center will soon be performing these interventions almost routinely,” said the specialist.

The first step has already been taken, and two Cubans —one from Havana and the other from Mayabeque— are now evolving stable and satisfactorily, with the hope of returning to a full life a little closer.

(By: Lisandra Farinas Acosta/Cubadebate)

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