Insuficiencia mitral isquémica: aspectos fisiopatológicos y terapéuticos / Ischemic mitral regurgitation: pathophysiology and therapeutic

La insuficiencia mitral de etiología isquémica, a diferencia de aquellas en las que existe compromiso “primario” de las valvas o del aparato subvalvular, tiene características propias que obligan a su análisis y abordaje con una visión diferente y muy particular. Se realizó una revisión de la literatura médica desde enero de 1995 hasta febrero 2007 bajo las palabras clave “ischemic mitral regurgitation” y se seleccionaron un total de 49 artículos relacionados con epidemiología de la insuficiencia mitral isquémica, la evaluación de sus mecanismos y las diferentes técnicas terapéuticas. Varios mecanismos han sido descritos entre los cuales están: desplazamiento, elongación o ruptura del músculo papilar, así como dilatación y deformación del anillo. Se han desarrollado diferentes técnicas terapéuticas en la insuficiencia mitral isquémica dirigidas a corregir cada uno de ellos: Prevención del remodelado postinfarto, reposicionamiento o reparación del músculo papilar, liberación o transposición de cuerdas tendinosas, plastia mitral y reemplazo valvular mitral, entre otras. La evaluación adecuada y la identificación individualizada, por parte del cardiólogo, de los mecanismos involucrados en la patogenia de la insuficiencia mitral isquémica, es determinante para lograr una correcta escogencia del tratamiento. Seguimiento a largo plazo de algunas técnicas terapéuticas empleadas es necesario para conocer su efectividad

Ischemic Mitral regurgitation, unlike those with a primary commitment of the valves and subvalvular apparatus, has particular characteristics that need an analysis and boarding with a different and special vision by the cardiologist. Was made an overhaul of medical publication from January 1995 to February 2007 with the key words “ischemic mitral regurgitation” and were selected a total of 49 articles related to ischemic mitral regurgitation epidemiology, evaluation of its mechanisms and the corresponding therapeutic techniques. Several mechanisms have been described: displacement, elongation or rupture of papillary muscle, as well as the expansion and deformation of the mitral ring. Different techniques directed to correct each one of these mechanisms have been developed: Post myocardial infarction remodeling prevention, papillary muscle relocation or repair, mitral chordae tendineae liberation or translocation, valve repair and valve replacement, among others. The suitable evaluation and individualized identification of the pathological mechanisms involved in the genesis of ischemic mitral regurgitation by de cardiologist is determinant for to choose the best therapy. Long term following of some therapeutic techniques is necessary for to know its effectiveness

Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: a multicenter study.

BACKGROUND: Cardiac examination is an essential aspect of the physical examination. Previous studies have shown poor diagnostic accuracy, but most used audio recordings, precluding correlation with visible observations. The training spectrum from medical students (MSs) to faculty has not been tested, to our knowledge. METHODS: A validated 50-question, computer-based test was used to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills using computer graphic animations and virtual patient examinations (actual patients filmed at the bedside). We tested 860 participants: 318 MSs, 289 residents (225 internal medicine and 64 family medicine), 85 cardiology fellows, 131 physicians (50 full-time faculty, 12 volunteer clinical faculty, and 69 private practitioners), and 37 others. RESULTS: Mean scores improved from MS1-2 to MS3-4 (P = .003) but did not improve or differ significantly among MS3, MS4, internal medicine residents, family medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (P<.001), and they were the best in all 4 subcategories of competency, whereas MS1-2 were the worst in the auditory and visual subcategories. Participants demonstrated low specificity for systolic murmurs (0.35) and low sensitivity for diastolic murmurs (0.49). CONCLUSIONS: Cardiac examination skills do not improve after MS3 and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care, and continuing medical education. Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.