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)
REPERT MED CIR. 2024;33(1):74-79
78
de Medicina y Cirugía
*Si está disponible. IABP: balón de contrapulsación intraaórtico; ECMO:
oxigenación por membrana extracorpórea;
IAM: (infarto agudo de miocardio); RSV: ruptura septum ventricular.
Fuente: los autores.
hospitalaria fue bueno y dieron a conocer la importancia
que tiene una adecuada selección del dispositivo, quizá 50%
más grande de la medida del defecto, ya que puede agravarse
al implantar el mismo. Varios factores se encontraron en los
pacientes que sobrevivieron, como mayor presión arterial
sistólica y diastólica, mejor función ventricular y clase
funcional New York Heart Association (NYHA).
22
Es clara
la necesidad de estudios grandes y de poder estadístico
para orientar mejor el tratamiento de dichos pacientes con
alta morbimortalidad. El manejo médico debe enfocarse en
disminuir la poscarga y de esa manera reducir el cortocircuito,
con vasodilatadores endovenosos (nitroprusiato de sodio)
y balón de contrapulsación intraaórtico. Algunos estudios
han documentado el uso de ECMO para estabilizar los
pacientes y llevarlos a cirugía, y otros reportes de caso han
descrito el uso de soporte circulatorio mecánico (Impella 5.0
y TandemHeart) en choque cardiogénico.
23
IAM + RSV
Estable con
defecto grande
Inestable
IABP o ECMO*
Cirugía inmediata
Cierre percutáneo
Defecto anteroapical < 1.5 cm
sin comprometer la válvula
Usar dispositivo 50% más
grande a la medida del
defecto por ecocardiograma
No candidato a cirugía
Estable con
defecto pequeño
Cierre:
Reducir poscarga
con IABP vs ECMO
Cirugía > 7 días
Manejo
conservador
Cierre
percutáneo
Los autores no declaran conicto de interés.
Ninguna.
Dra. Francy Rivera Residente de 1er año anestesiología,
FUCS. Juan Bedoya, residente de 1er año medicina interna-
FUCS, por su colaboración en algunos datos de los casos.
CONFLICTO DE INTERÉS
FINANCIACIÓN
AGRADECIMIENTOS
REFERENCIAS
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