Presentation on theme: "Sur gical Ventricular Remodeling for Congestive Heart Failure"— Presentation transcript:
1Sur gical Ventricular Remodeling for Congestive Heart Failure “When BB and ACEI are not Enough”May 18th 2006Jeffrey MarogilMalek Massad
2Heart Failure Introduction Major Health Concern in USAffects 4.8 million people in U.S.400,000 new cases each year.Anticipated increase in incidence & prevalence as population ages.
3INTRODUCTIONSignificant progress has been made in the medical management of patients with heart failureHowever the surgical management of patients with end-stage heart failure has evolved in a less structured fashion
4INTRODUCTIONHeart transplantation remains the ultimate treatment for heart failure
5INTRODUCTIONCardiac 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
6INTRODUCTIONCardiac 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 guidelinesSmall number of available donor heartsInapplicable in older pts or those with comorbid conditions
7NUMBER 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.
8Need for Heart Transplant # of Potential Recipients that can Benefit from OHT
10ADULT 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.
11Who Should Not Be Offered a Heart Transplant? Irreversible PHTN or pulmonary parenchymal diseaseIrreversible renal or hepatic dysfunctionSevere peripheral or cerebrovascular diseaseIDDM with end-organ damageCoexisting cancerNon-compliance, addictionElderly patients (aprox > 70yo)
12Surgical Ventricular Remodeling Other Surgical Treatment Options are needed since transplants limited byAvailable donorsSuitable recipients
13Surgical Treatment of heart failure Coronary revascularization in ischemic cardiomyopathyMitral valve repair in patients with dilated cardiomyopathy.Left ventricular assist devices (LVADs)Resynchronization therapyTotal Artificial HeartReconstructive cardiac surgery
142005 ACC/AHA GuidelinesAlternate 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 theDiagnosis and Management August 16, 2005
15Surgical remodeling for heart Failure Theory behind treatmentHistory of proceduresIschemicBatistaLeft ventricular aneurysmectomyNonischemicCardiomyoplastyCurrent and Future LV Reconstructive proceduresDor procedureNon-ischemicAcorn & myosplintConclusions
16TheorySystolic HF leads to an enlarged LV volume to maintain stroke volumeThis leads to increase in wall stress due to Laplace's lawstress = pressure x radius ÷ 2 x wall thicknessThe ventricular geometry becomes less ellipsoid and more spherical leading to progression of left ventricular dysfunction and worsening heart failure.
17TheoryRemoving or excluding portions of the dysfunctional myocardium returns the left ventricular cavity to a smaller chamber with more normal geometryThis should improve cardiac work efficiency and theoretically should improve heart failure symptoms.Ideally it would also translate into prolonged survival
18TheoryIn the 1990’s studies showed a relationship between LV size and Mortality
19Theory 382 patients with NYHA III and IV LV size measured by EDV/BSA LV size was a predictor of sudden cardiac deathLV’s > 4 cm/m2 had a 2 year survial of 49% compared to 75% if < 4 cm/m2Independent of disease and %EFLee th et al Am J Cardiology 1993;72:
20Surgical remodeling for heart Failure Theory behind treatmentHistory of proceduresIschemicBatistaLeft ventricular aneurysmectomyNonischemicCardiomyoplathyCurrent and Future LV Reconstructive proceduresDor procedureNon-ischemicAcorn & myosplintConclusions
21Batista procedureBatista procedure also called the partial left ventriculectomy (PLV)Developed by Dr. Randas Batista (Brazil) in 1996
22Partial 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 annulusRemaining free edges were re- -approximated and stitched togetherMitral valve and subvalvular apparatus were either preserved, repaired, or replaced,
23Partial Left Ventriculectomy (Batista Operation) UIC
24Partial 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 statusHowever, of 120 patients Batista reported a 22% operative mortality and 2 year survival of 55%.
25Partial Left Ventriculectomy (Batista Operation) Late fatal arrhythmias plagued this procedure, forcing the use of concomitant implantable defibrillatorsTherefore the Batista procedure has fallen out of favor and is no longer considered to be an appropriate option
26Surgical remodeling for heart Failure Theory behind treatmentHistory of proceduresIschemicBatistaLeft ventricular aneurysmectomyNonischemicCardiomyoplathyCurrent and Future LV Reconstructive proceduresDor procedureNon-ischemicAcorn & myosplintConclusions
27Left ventricular aneurysmectomy The first successful surgical correction of an LV aneurysm occurred in 1957 by Dr. BaileyDone without off cardiac bypass by placing a clamp on the base of an aneurysm and passing suture beneath allowing excision of the aneurysm.
28Left 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.
29Left 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
30Surgical remodeling for heart Failure Theory behind treatmentHistory of proceduresIschemicBatistaLeft ventricular aneurysmectomyNonischemicCardiomyoplathyCurrent and Future LV Reconstructive proceduresDor procedureNon-ischemicAcorn & myosplintConclusions
31CardiomyoplastyCardiomyoplasty, 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.
32CardiomyoplastyCarpentier and Chachques peformed the first successful surgery on a humen in 1985
33Cardiomyoplasty Symptomatic improvement occured after cardiomyoplasty Mechanism for improvement is unclearPacemaker synchronization was critical for obtaining optimal improvement.
34Cardiomyoplasty600 patients undergoing this procedure found that, over time, the operative mortality decreased from 31 to 3 percentImprovement in NYHA classification occurred in 80 to 85 percent of hospital survivorsHowever, long-term outcome data with cardiomyoplasty are limited.
35CardiomyoplastyA large, randomized clinical trial of cardiomyoplasty was initiated for NYHA class III heart failure patientsPlagued by lagging randomization and marginal overall clinical improvement culminated in the premature termination of the study.
36Cardiomyoplasty“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.
372005 ACC/AHA GuidelinesAlthough 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 deathChronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for theDiagnosis and Management August 16, 2005
382005 ACC/AHA GuidelinesA 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 theDiagnosis and Management August 16, 2005
39Surgical remodeling for heart Failure Theory behind treatmentHistory of proceduresIschemicBatistaLeft ventricular aneurysmectomyNonischemicCardiomyoplathyCurrent and Future LV Reconstructive proceduresDor procedureNon-ischemicAcorn & myosplintConclusions
40LV 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 1985Advantage to aneurysmectomy is in an attempt to restore left ventricular geometry
41Dor 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.
42Dor 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
43Dor 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
44Dor 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
45Dor procedure for Ischemic Cardiomyopathy The first 661 patientsOverall 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
46Dor procedure for Ischemic Cardiomyopathy 495 patients available for follow-up, there was dramatic improvementsOverall 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.
47LV Reconstruction for Ischemic Cardiomyopathy At present there are four variations of LV reconstruction are used excluding the septumLinear closure by JateneModified liner closure by MickleboroughCircular closure with a path by DorCircular closure without a patch by McCarthy
48LV 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 FailureJournal of Cardiac Failure Vol 12 No
49LV Reconstruction for Ischemic Cardiomyopathy 74 Consecutive patients with ischemic cardiomyopathy and EF < 35% with LESV > 80ml/m2
50LV Reconstruction for Ischemic Cardiomyopathy LimitationsNon-BlindedExcluded > 2+ MR or other significant valvular heart diseaseDyskinetic ant wallNon-viable Ant wall on Thallium testing
55LV Reconstruction for Ischemic Cardiomyopathy STICH TrialNIH 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/m600 patient scheduled to enroll
56Considered Criteria for Surgical Repair Anteroseptal MI, with dilated left ventricle (end-diastolic volume index >100 mL/m2)Depressed LVEFLeft ventricular regional dyskinesis or akinesis >30 percent of the ventricular perimeter, andEither symptoms of angina, heart failure, or arrhythmias
57The following are considered to be relative contraindications Systolic pulmonary artery pressure >60 mmHgSevere right ventricular dysfunctionRegional dyskinesis or akinesis without dilation of the ventricle
58Surgical remodeling for heart Failure Theory behind treatmentHistory of proceduresIschemicBatistaLeft ventricular aneurysmectomyNonischemicCardiomyoplathyCurrent and Future LV Reconstructive proceduresDor procedureNon-ischemicAcorn & myosplintConclusions
59LV 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 wrapThis observation led to the development of the Acorn device and Myosplint
60LV Reconstruction for Non-ischemic Cardiomyopathy Acorn deviceknitted polyester sock that is drawn up and anchored over the ventricles in order to limit left ventricular dilationPreliminary data suggest that the device produces an improvement in heart failure symptoms, LVEF, left ventricular end-diastolic dimension, and quality of life
61LV Reconstruction for Non-ischemic Cardiomyopathy Study of 27 pt NYHA class went from mean 2.5 to 1.7After one year, there is no evidence of constriction and coronary blood flow reserve remained normalLarger clinical trials of this device in the United States and Europe are ongoing
62LV Reconstruction for Non-ischemic Cardiomyopathy MyosplintTwo epicardial pads and a tension wireTwo pads on the surface of the heartWire passes throughthe ventriclePlaced under tension toto create a bilobularshape
63LV Reconstruction for Non-ischemic Cardiomyopathy 21 consecutive patients, 9 patients received a Myosplint device alone while 12 patients underwent a mitral valve repair as wellNYHA 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 monthsNo serious device-related adverse events or device failures were observedJ Card Surg Nov-Dec;20(6):S43-7.
64Surgical remodeling for heart Failure Theory behind treatmentHistory of proceduresIschemicBatistaLeft ventricular aneurysmectomyNonischemicCardiomyoplathyCurrent and Future LV Reconstructive proceduresDor procedureNon-ischemicAcorn & myosplintConclusions
65ConclusionVentricular resonstruction attempts to restore the geometry of the diseased heartSeveral promising surgical therapies for ischemic and non-ischemic cardiomyopathy are being developedIn Ischemic CM select patient may already be able to benefit from therapyResults of the STICH Trial will help and define the role or SVR in ischemic heart failure
66ConclusionThe Role surgical therapy in Non-ischemic is not clearly defined but promising studies are underway