1. Sur gical Ventricular Remodeling for Congestive Heart Failure
“When BB and ACEI are not Enough”
May 18th 2006
Jeffrey Marogil
Malek Massad

2. Heart Failure Introduction
Major Health Concern in US
Affects 4.8 million people in U.S.
400,000 new cases each year.
Anticipated increase in incidence & prevalence as population ages.

3. INTRODUCTION
Significant progress has been made in the medical management of patients with heart failure
However the surgical management of patients with end-stage heart failure has evolved in a less structured fashion

4. INTRODUCTION
Heart transplantation remains the ultimate treatment for heart failure

5. INTRODUCTION
Cardiac transplantation is currently the only established surgical approach (excluding AVR and CABG) for the treatment of refractory HF as listed in the 2005 ACC/AHA heart failure guidelines

6. INTRODUCTION
Cardiac transplantation is currently the only established surgical approach (excluding AVR and CABG) for the treatment of refractory HF as listed in the 2005 ACC/AHA heart failure guidelines
Small number of available donor hearts
Inapplicable in older pts or those with comorbid conditions

7. NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR AND LOCATION
This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of hearts transplanted worldwide has declined in recent years.

8. Need for Heart Transplant # of Potential Recipients that can Benefit from OHT

9. HEART TRANSPLANTATION
ACTUARIAL SURVIVAL ( )
Half-life =9.1 years
Conditional Half-life = 11.6 years
N=52,195

10. ADULT HEART TRANSPLANTATION Actuarial Survival by Diagnosis (Transplants: 1/1982-6/2001)
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow-up, the survival rates are estimates rather than exact rates because the time of death is not know for all patients. The half-life is the estimated time point at which 50% of all of the recipients have died.
Survival rates were compared using the log-rank test statistic.

11. Who Should Not Be Offered a Heart Transplant?
Irreversible PHTN or pulmonary parenchymal disease
Irreversible renal or hepatic dysfunction
Severe peripheral or cerebrovascular disease
IDDM with end-organ damage
Coexisting cancer
Non-compliance, addiction
Elderly patients (aprox > 70yo)

12. Surgical Ventricular Remodeling
Other Surgical Treatment Options are needed since transplants limited by
Available donors
Suitable recipients

13. Surgical Treatment of heart failure
Coronary revascularization in ischemic cardiomyopathy
Mitral valve repair in patients with dilated cardiomyopathy.
Left ventricular assist devices (LVADs)
Resynchronization therapy
Total Artificial Heart
Reconstructive cardiac surgery

14. 2005 ACC/AHA Guidelines
Alternate surgical and mechanical approaches for the treatment of end-stage HF are under development.
Chronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for the
Diagnosis and Management August 16, 2005

15. Surgical remodeling for heart Failure
Theory behind treatment
History of procedures
Ischemic
Batista
Left ventricular aneurysmectomy
Nonischemic
Cardiomyoplasty
Current and Future LV Reconstructive procedures
Dor procedure
Non-ischemic
Acorn & myosplint
Conclusions

16. Theory
Systolic HF leads to an enlarged LV volume to maintain stroke volume
This leads to increase in wall stress due to Laplace's law
stress = pressure x radius ÷ 2 x wall thickness
The ventricular geometry becomes less ellipsoid and more spherical leading to progression of left ventricular dysfunction and worsening heart failure.

17. Theory
Removing or excluding portions of the dysfunctional myocardium returns the left ventricular cavity to a smaller chamber with more normal geometry
This should improve cardiac work efficiency and theoretically should improve heart failure symptoms.
Ideally it would also translate into prolonged survival

18. Theory
In the 1990’s studies showed a relationship between LV size and Mortality

19. Theory 382 patients with NYHA III and IV LV size measured by EDV/BSA
LV size was a predictor of sudden cardiac death
LV’s > 4 cm/m2 had a 2 year survial of 49% compared to 75% if < 4 cm/m2
Independent of disease and %EF
Lee th et al Am J Cardiology 1993;72:

20. Surgical remodeling for heart Failure
Theory behind treatment
History of procedures
Ischemic
Batista
Left ventricular aneurysmectomy
Nonischemic
Cardiomyoplathy
Current and Future LV Reconstructive procedures
Dor procedure
Non-ischemic
Acorn & myosplint
Conclusions

21. Batista procedure
Batista procedure also called the partial left ventriculectomy (PLV)
Developed by Dr. Randas Batista (Brazil) in 1996

22. Partial Left Ventriculectomy (Batista Operation)
Removal of a section of the left ventricular free wall, between both papillary muscles and extending from the apex to the mitral annulus
Remaining free edges were re- -approximated and stitched together
Mitral valve and subvalvular apparatus were either preserved, repaired, or replaced,

23. Partial Left Ventriculectomy (Batista Operation)
UIC

24. Partial Left Ventriculectomy (Batista Operation)
Initial experience with the Batista procedure demonstrated an initial increase in LVEF, reduction in heart size, and improvement in clinical functional status
However, of 120 patients Batista reported a 22% operative mortality and 2 year survival of 55%.

25. Partial Left Ventriculectomy (Batista Operation)
Late fatal arrhythmias plagued this procedure, forcing the use of concomitant implantable defibrillators
Therefore the Batista procedure has fallen out of favor and is no longer considered to be an appropriate option

26. Surgical remodeling for heart Failure
Theory behind treatment
History of procedures
Ischemic
Batista
Left ventricular aneurysmectomy
Nonischemic
Cardiomyoplathy
Current and Future LV Reconstructive procedures
Dor procedure
Non-ischemic
Acorn & myosplint
Conclusions

27. Left ventricular aneurysmectomy
The first successful surgical correction of an LV aneurysm occurred in 1957 by Dr. Bailey
Done without off cardiac bypass by placing a clamp on the base of an aneurysm and passing suture beneath allowing excision of the aneurysm.

28. Left ventricular aneurysmectomy
Dr. Denton Cooley performed a resection of an LV aneurysm one year later on bypass which remained the standard for nearly 30 years.

29. Left ventricular aneurysmectomy
A 2004 ACC/AHA task force concluded that it is reasonable (class IIa recommendation) to consider aneurysmectomy, accompanied by coronary artery bypass grafting (CABG), in patients with a left ventricular aneurysm in the setting of an acute MI who have intractable ventricular arrhythmias and/or heart failure unresponsive to medical and catheter-based therapy

30. Surgical remodeling for heart Failure
Theory behind treatment
History of procedures
Ischemic
Batista
Left ventricular aneurysmectomy
Nonischemic
Cardiomyoplathy
Current and Future LV Reconstructive procedures
Dor procedure
Non-ischemic
Acorn & myosplint
Conclusions

31. Cardiomyoplasty
Cardiomyoplasty, also referred to as "dynamic cardiomyoplasty,"
Surgical therapy for dilated cardiomyopathy in which the latissimus dorsi muscle is wrapped around the heart and paced during ventricular systole.

32. Cardiomyoplasty
Carpentier and Chachques peformed the first successful surgery on a humen in 1985

33. Cardiomyoplasty Symptomatic improvement occured after cardiomyoplasty
Mechanism for improvement is unclear
Pacemaker synchronization was critical for obtaining optimal improvement.

34. Cardiomyoplasty
600 patients undergoing this procedure found that, over time, the operative mortality decreased from 31 to 3 percent
Improvement in NYHA classification occurred in 80 to 85 percent of hospital survivors
However, long-term outcome data with cardiomyoplasty are limited.

35. Cardiomyoplasty
A large, randomized clinical trial of cardiomyoplasty was initiated for NYHA class III heart failure patients
Plagued by lagging randomization and marginal overall clinical improvement culminated in the premature termination of the study.

36. Cardiomyoplasty
“It appears that those who can survive the operation do not need it and those who need it, cannot survive it”
Leier, CV. Cardiomyoplasty: is it time to wrap it up?. J Am Coll Cardiol 1996; 28:1181.

37. 2005 ACC/AHA Guidelines
Although both cardiomyoplasty and left ventriculectomy (Batista procedure) at one time generated considerable excitement as potential surgical approaches to the treatment of refractory HF these procedures failed to result in clinical improvement and were associated with a high risk of death
Chronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for the
Diagnosis and Management August 16, 2005

38. 2005 ACC/AHA Guidelines
A variant of the aneurysmectomy procedure is now being developed for the management of patients with ischemic cardiomyopathy, but its role in the management of HF remains to be defined.
Chronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for the
Diagnosis and Management August 16, 2005

39. Surgical remodeling for heart Failure
Theory behind treatment
History of procedures
Ischemic
Batista
Left ventricular aneurysmectomy
Nonischemic
Cardiomyoplathy
Current and Future LV Reconstructive procedures
Dor procedure
Non-ischemic
Acorn & myosplint
Conclusions

40. LV Reconstruction for Ischemic Cardiomyopathy
Dor procedure also called endoventricular circular patch plasty (EVCPP), is an approach to surgical reconstruction in the setting of postinfarction aneurysm formation first reported in 1985
Advantage to aneurysmectomy is in an attempt to restore left ventricular geometry

41. Dor procedure for Ischemic Cardiomyopathy
May be considered in patients with symptomatic aneurysms as defined by heart failure, angina pectoris, systemic embolization, and/or malignant ventricular tachyarrhythmias.

42. Dor procedure for Ischemic Cardiomyopathy
Purse string stitch around a nonviable scarred aneurysm to minimize the excluded area. The residual defect is sometimes covered by a patch made from Dacron, pericardium, or an autologous tissue flap

43. Dor procedure for Ischemic Cardiomyopathy
The remaining aneurysmal scar is closed over the outside of the patch to give additional stability to the repair. The result is a more normal left ventricular chamber geometry and overall function

44. Dor procedure for Ischemic Cardiomyopathy
The operation shortens the long axis, but leaves the short axis length unchanged, producing an increase in ventricular diastolic sphericity while the systolic shape becomes more elliptical

45. Dor procedure for Ischemic Cardiomyopathy
The first 661 patients
Overall operative mortality was 8 percent; (urgently 16.3 versus 6.2 percent when planned)
LVEF less than 20 percent (17 versus 1.4 percent for LVEF greater than 40 percent)
Jpn J Thorac Cardiovasc Surg 1998 May;46(5):389-98

46. Dor procedure for Ischemic Cardiomyopathy
495 patients available for follow-up, there was dramatic improvements
Overall LVEF improved from 33% versus 50% at one week postoperatively) maintained at one year.
The end-diastolic volume index decreased and symptomatic heart failure status, (212 pt) at one year, improved in 92 percent;
In addition, 91 percent of patients with spontaneous ventricular tachycardia were free of arrhythmia at one year.

47. LV Reconstruction for Ischemic Cardiomyopathy
At present there are four variations of LV reconstruction are used excluding the septum
Linear closure by Jatene
Modified liner closure by Mickleborough
Circular closure with a path by Dor
Circular closure without a patch by McCarthy

48. LV Reconstruction for Ischemic Cardiomyopathy
First randomized trial of surgical ventricular restoration + CABG vs CABG alone for ischemic cardiomyopathy was published April 2006 isure of Journal of Cardiac Failure
Journal of Cardiac Failure Vol 12 No

49. LV Reconstruction for Ischemic Cardiomyopathy
74 Consecutive patients with ischemic cardiomyopathy and EF < 35% with LESV > 80ml/m2

50. LV Reconstruction for Ischemic Cardiomyopathy
Limitations
Non-Blinded
Excluded > 2+ MR or other significant valvular heart disease
Dyskinetic ant wall
Non-viable Ant wall on Thallium testing

51. LV Reconstruction for Ischemic Cardiomyopathy

52. LV Reconstruction for Ischemic Cardiomyopathy

55. LV Reconstruction for Ischemic Cardiomyopathy
STICH Trial
NIH sponsored trial to compare medical therapy vs CABG for patients with CHF and EF < 35% including SVR + CABG as a treatment arm in patients with LVESVI > 60ml/m
600 patient scheduled to enroll

56. Considered Criteria for Surgical Repair
Anteroseptal MI, with dilated left ventricle (end-diastolic volume index >100 mL/m2)
Depressed LVEF
Left ventricular regional dyskinesis or akinesis >30 percent of the ventricular perimeter, and
Either symptoms of angina, heart failure, or arrhythmias

57. The following are considered to be relative contraindications
Systolic pulmonary artery pressure >60 mmHg
Severe right ventricular dysfunction
Regional dyskinesis or akinesis without dilation of the ventricle

58. Surgical remodeling for heart Failure
Theory behind treatment
History of procedures
Ischemic
Batista
Left ventricular aneurysmectomy
Nonischemic
Cardiomyoplathy
Current and Future LV Reconstructive procedures
Dor procedure
Non-ischemic
Acorn & myosplint
Conclusions

59. LV Reconstruction for Non-ischemic Cardiomyopathy
Cardiomyoplasty experience has led to other novel approaches to heart failure.
Observations suggested that some patients benefited from the diastolic "girdling" effect of the muscle wrap
This observation led to the development of the Acorn device and Myosplint

60. LV Reconstruction for Non-ischemic Cardiomyopathy
Acorn device
knitted polyester sock that is drawn up and anchored over the ventricles in order to limit left ventricular dilation
Preliminary data suggest that the device produces an improvement in heart failure symptoms, LVEF, left ventricular end-diastolic dimension, and quality of life

61. LV Reconstruction for Non-ischemic Cardiomyopathy
Study of 27 pt NYHA class went from mean 2.5 to 1.7
After one year, there is no evidence of constriction and coronary blood flow reserve remained normal
Larger clinical trials of this device in the United States and Europe are ongoing

62. LV Reconstruction for Non-ischemic Cardiomyopathy
Myosplint
Two epicardial pads and a tension wire
Two pads on the surface of the heart
Wire passes through
the ventricle
Placed under tension to
to create a bilobular
shape

63. LV Reconstruction for Non-ischemic Cardiomyopathy
21 consecutive patients, 9 patients received a Myosplint device alone while 12 patients underwent a mitral valve repair as well
NYHA functional class went from 3.0 +/- 0.3 at baseline to 2.1 +/- 0.7 at 6 months (p = 0.001).
The LV ejection fraction significantly increased in the Myosplint alone group (from /- 4.0% at baseline to /- 7.2% at 6 months
No serious device-related adverse events or device failures were observed
J Card Surg Nov-Dec;20(6):S43-7.

64. Surgical remodeling for heart Failure
Theory behind treatment
History of procedures
Ischemic
Batista
Left ventricular aneurysmectomy
Nonischemic
Cardiomyoplathy
Current and Future LV Reconstructive procedures
Dor procedure
Non-ischemic
Acorn & myosplint
Conclusions

65. Conclusion
Ventricular resonstruction attempts to restore the geometry of the diseased heart
Several promising surgical therapies for ischemic and non-ischemic cardiomyopathy are being developed
In Ischemic CM select patient may already be able to benefit from therapy
Results of the STICH Trial will help and define the role or SVR in ischemic heart failure

66. Conclusion
The Role surgical therapy in Non-ischemic is not clearly defined but promising studies are underway