Capítulo 8

Trombosis intracardíaca

Verónica Cortés Guerrieri, Paulo Colimodio

Introducción

La trombosis intracardíaca es detectada en general en las autopsias, sin embargo su prevalencia y su potencial morbilidad se hace más evidente por el mayor uso de estudios de imágenes. Puede ocurrir de novo en cualquiera de las cuatro cámaras (auricular, ventricular derecha o izquierda y sus apéndices), ser un trombo en tránsito originado en otra parte del cuerpo o desarrollarse en asociación con dispositivos intracardíacos. Se puede clasificar según la etiología en primarias (idiopáticas) o secundarias. Estas últimas son más frecuentes y se deben en su gran mayoría a fibrilación auricular y a patología estructural cardíaca como dilatación de cavidades, secundaria a infarto agudo de miocardio (IAM), insuficiencia cardíaca congestiva (ICC) en estadío avanzado, miocardiopatía dilatada (MCPD), comunicación inter-auricular o ventricular, trombosis de prótesis valvulares, etc (1, 2).

La trombosis de cavidades derechas se origina en su gran mayoría en las venas de los miembros inferiores y puede alojarse transitoriamente en aurícula o ventrículo derecho, se denomina trombo en tránsito y tiene una alta probabilidad de embolia de pulmón (comparten fisiopatología y tratamiento con la enfermedad tromboembólica venosa) (3).

Otras causas menos frecuentes las constituyen las malformaciones anatómicas congénitas (membranas, miocardio no compacto), los tumores intracardíacos, miocardiopatías infiltrativas (amiloidosis, etc.), estados de hipercoagulabilidad (cáncer, colagenopatías, sepsis, síndrome antifosfolípido, trombofilia hereditaria).

En esta revisión nos enfocaremos en la trombosis ventricular izquierda, mencionaremos las cardiopatías congénitas del adulto y la trombosis de válvula protésica mecánica.

Trombo intraventricular izquierdo (TIVI)

El TIVI es una complicación típica luego del IAM, pero también puede ocurrir en otras situaciones clínicas que lleven a alteraciones de la motilidad de la pared como la MCPD, miocarditis, miocardiopatía de Takotsubo. Otras causas son: síndrome antifosfolípido, distrofias musculares, enfermedad de Behcet, fibrosis endocárdica de Loeffler.

En la era de la angioplastia la incidencia de TIVI se redujo del 20 al 4% en los pacientes post IAM. La fisiopatogenia se debe a anormalidades de la contractilidad con rémora sanguínea y ectasia. El volumen de inicio y de fin de sístole aumentados y la fracción de eyección menor de 35% son los mayores predictores de formación de trombo. Los cambios inflamatorios asociados a IAM también pueden favorecer la trombogénesis, es así que la mayor elevación de la proteína C reactiva sérica se asocia a mayor incidencia de TIVI luego de IAM.

La presencia de TIVI post IAM se asocia a un pobre pronóstico (IAM anterior extenso con compromiso de la punta tiene mayor riesgo embólico). La protrusión del trombo dentro de la cavidad y la movilidad del mismo aumentan el riesgo embólico. Aquellos pacientes que sufren un evento embólico tienen mayor mortalidad (39%versus 10,3%). En pacientes con miocardiopatia dilatada terminal la incidencia de trombo es de 11 a 44%.

La resonancia magnética tiene la mayor sensibilidad (88%) y especificidad (99%) para la detección del TIVI, comparado con ecocardiograma transtorácico (ETT) (23% y 96% respectivamente) y ecocardiograma transesofágico (ETE) (40% y 96 % respectivamente). La sensibilidad y la especificidad del ecocardiograma aumenta cuando el estudio se hace orientado en la búsqueda de TIVI (60-75%). La ecocardiografia tridimensional provee mayor información en cuanto a la estructura del trombo. No hay datos concluyentes de la tomografía computada (1).

Tratamiento

No hay regímenes estandarizados. Los algoritmos actuales están basados en trabajos retrospectivos de pocos pacientes. Incluyen trombectomía, heparina no fraccionada (HNF), heparina de bajo peso molecular (HBPM), anticoagulación oral (AVK) y trombolíticos.

Heik y col. demostraron resolución completa del TIVI en 83% de los casos de trombo con alto riesgo de embolización con HNF (4) y Meurin y col. 73% de resolución con HBPM (5). Los AVK mostraron una alta variabilidad en la resolución completa entre 13% y 59% (6). El uso de trombolíticos no se recomienda pese a que mostró ser efectivo (lisis completa) en un 60 a 70% de los casos publicados. Esto se debe al reporte de aumento de eventos embólicos y hemorrágicos asociados a dicho tratamiento. La trombectomía quirúrgica es una alternativa en pacientes con disfunción ventricular severa con trombo móvil y protruyente. Los estudios publicados no encontraron diferencias entre el tratamiento farmacológico y quirúrgico (7).

El American College of Cardiology Foundation / American Heart Association Task ACC/AHA recomiendan el uso de AVK con un RIN 2-3 en pacientes con TIVI por al menos 3 meses (clase IB) y quizás indefinido en pacientes sin riesgo aumentado de sangrado (clase IC). Según la Sociedad Europea de Cardiología la duración del tratamiento con el trombo diagnosticado debe ser de al menos 3 meses y hasta 6 meses (clase IIb B) (9).

En pacientes con disfunción ventricular severa la fracción de eyección es el factor de riesgo que se asocia independientemente a stroke y eventos embólicos.

La profilaxis tromboembólica en pacientes con MCPD con ritmo sinusal no está aún definida. Los AVK no reducen la morbi-mortalidad comparado con aspirina, clopidogrel o placebo en pacientes con MCPD y fracción de eyección reducida (10). Hay estudios que demostraron que el tratamiento con AVK redujo la incidencia de TIVI en pacientes con alteración severa de la motilidad de la pared anterior del ventrículo por IAM. La Sociedad Europea de Cardiología recomienda considerar la anticoagulación en este tipo de pacientes, en caso de tener bajo riesgo de sangrado para prevenir la formación de TIVI. ACC/AHA sugieren el uso de AVK con un RIN 2-3 en pacientes con ICC con disfunción sistólica y eventos tromboembólicos previos.

En pacientes con IAM con elevación del ST el ACC/AHA sugiere que el tratamiento con AVK debe ser considerado en pacientes con trombo mural de ventrículo izquierdo (clase IIa C) y en pacientes con aquinesia o disquinesia anterior y apical (Clase IIb C). Así mismo debe considerarse un RIN 2-2,5 en pacientes que reciben concomitantemente doble terapia antiplaquetaria (11). Esta combinación aumenta el riesgo de sangrado. Se desconoce la duración óptima de la triple terapia antitrombótica y hay que considerar los riesgos relativos de sangrado y de trombosis del stent. Se aconseja repetir las imágenes a los 3 meses y si el trombo desaparece y hay mejoría de la motilidad parietal discontinuar el AVK. Esto no ha sido validado por estudios randomizados.

TROMBOSIS EN CARDIOPATIAS CONGÉNITAS DEL ADULTO (CPCA)

Las alteraciones anatómicas congénitas con riesgo aumentado de trombosis y stroke incluyen la transposición de grandes arterias con defectos del tabique luego de cirugía reparadora; corrección de hipoplasia ventricular izquierda con cirugía de Fontan; estenosis mitral; anomalía de Ebstein y shunt interauricular de alto grado (con o sin alteraciones asociadas: aneurisma septal, membranas).

Si bien no hay estudios que determinen una conducta clara, las recomendaciones actuales sugieren tratamiento anticoagulante oral en CPCA con AVK cuando hay antecedente de trombosis previa o presenta fibrilación o aleteo auricular asociado (Clase IC). En la cirugía de Fontan la indicación de AVK como prevención primaria de stroke se inicia cuando persiste shunt auricular remanente (Clase IIC) y secundaria, luego de evento embólico previo (Clase IA) (12).

Cabe mencionar que las alteraciones hemorreológicas secundarias a cardiopatías con shunt de derecha a izquierda pueden jugar un rol en el estado hipercoagulable. La eritrocitosis por hipoxemia, lleva a la hiperviscosidad y aumento de la activación endotelial y plaquetaria. Un estudio realizado en pacientes portadores de CPCA con cianosis demostró aumento de la agregación plaquetaria con altos niveles de P-selectina y de complejos trombina-antitrombina, asociados a baja actividad de trombomodulina y concentración de proteína C, lo cual sugiere disfunción endotelial secundaria.

Se recomienda flebotomías para mantener valores de Hb <20gr/dl y Hto <65% (Clase IIC) (13).

TROMBOSIS DE VÁLVULA PROTÉSICA MECÁNICA

La incidencia de trombosis de válvula protésica mecánica es de 1.3% pacientes por año (p/a) en países desarrollados y de 6,2% p/a en países subdesarrollados. Es menos frecuente en las válvulas biológicas. El diagnóstico diferencial es con el pannus o tejido fibroso. El ETT se utiliza para la evaluación hemodinámica. El ETE se realiza para certificar la presencia del trombo, su caracterización, y evaluar la función valvular. En algunos casos es necesario realizar adicionalmente una TC para completar la evaluación.

La decisión terapéutica se basa en el compromiso hemodinámico del paciente, la localización de la trombosis valvular (izquierda o derecha) y el tamaño del trombo. Para pacientes con trombosis de prótesis valvulares izquierdas de comienzo reciente (menor a 14 días), clase funcional I/II y trombo pequeño (< 0,8 cm2) es razonable el uso de trombolíticos (exceptuando aquéllos pacientes con contraindicación para recibir estas drogas) (AHA/ACC IIa B). Esta indicación es también válida para las trombosis de prótesis valvulares derechas. Cuando los síntomas son moderados y el trombo es pequeño es prudente reevaluar el paciente luego de varios días de HNF endovenosa. Si la trombosis persiste administrar activador tisular del plasminógeno recombinante (r-tPA): un bolo de 10 mg endovenoso seguido de una infusión continua de 90 mg en 2 horas. Si la trombolísis es efectiva se continúa con goteo de HNF hasta alcanzar un RIN 3-4 para la válvula en posición aórtica y RIN 3,5-4,5 para la mitral (14).

El estudio TROIA Trial Comparison of Different TEE-Guided Thrombolytic Regimens for Prosthetic Valve Thrombosis demostró que dosis menores de TPA repetidas según necesidad en infusión lenta son seguras y eficaces en el tratamiento de la trombosis valvular (15). La cirugía de urgencia se recomienda para pacientes con trombosis de válvula protésica izquierda con clase funcional III/IV (AHA/ACC clase I B). Es razonable también la cirugía en presencia de trombos móviles o grandes (> 0.8 cm2) (clase IIa C) (14).

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  3. Torbicki A, Galie N, Covezzoli A et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003; 41: 2245–51.
  4. Warnes C, Williams R, Bashore T et al. ACC/AHA 2008 guidelines for managment of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2008; 52: e143-e263.
  5. Heik S, Kupper W, Hamm C et al. Efficacy of high dose intravenous heparin for treatment of left ventricular thrombi with high embolic risk. J Am Coll Cardiol 1994; 24: 1305–9.
  6. Meurin P, Tabet J, Renaud N et al. Treatment of left ventricular thrombi with a low molecular weight heparin. Int J Cardiol 2005; 98:319–23.
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  8. Lee J, Park J, Jung H et al. Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents. J Atheroscler Thromb 2012; 20(1):73–93.
  9. Massie B, Collins J, Ammon S et al. Randomized trial of warfarin, aspirin, and clopidogrel in patients with chronic heart failure: the Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial. Circulation 2009; 119: 1616–24.
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