El enfermo valvular inoperable: ¿deberíamos ofrecer sustitución valvular percutánea?

Surgical valve replacement is the treatment of choice in patients with severe valvular heart disease. However, published data clearly show that long-term survival is seriously compromised in those with a low inotropic reserve. In addition, a growing number of patients (estimated to be around 15% of those with aortic stenosis) present in such a poor and deteriorating clinical condition that they cannot be accepted for surgery because it involves a very high risk of death. Percutaneous balloon valvuloplasty is a less aggressive alternative which offers a form of palliative treatment that can increase the patient's life expectancy and bring about immediate hemodynamic and clinical improvement. It is in this context that the possibility of carrying out percutaneous valve replacement has become available as a novel therapeutic option since Cribier first reported using the procedure to treat a patient with severe aortic stenosis. Since this first operation, both the techniques employed and the material composition of the prosthesis have undergone substantial development. However, significant problems have been encountered in evaluating the safety and efficacy of percutaneous valve replacement. These, to a great extent, stem from the risks associated with treating elderly patients who have high morbidity and mortality. In the United States, one clinical study was even suspended because two of the first four patients undergoing treatment died. In contrast, studies carried out in other countries, although they have involved only a few patients, have produced more promising results. Moreover, because the cause of death in these series was frequently due to factors that were independent of good valvular function, the future of the technique is generally thought to be positive. Nevertheless, the results obtained with percutaneous mitral valve replacement have been poor. In conclusion, the technique of percutaneous valve replacement, although still undergoing development, is becoming established as a viable alternative for treating inoperable valve disease, at least in aortic valves.