1. Paolo FerrazziRozzano 17 aprile 2009 Paolo Ferrazzi Dipartimento Cardiovascolare Ospedali Riuniti Bergamo Ninth International Symposium HEART FAILURE & Co. Rozzano,April 17, 2009 What Can the Surgeon Do to Avoid Heart Replacement?

2. Paolo FerrazziRozzano 17 aprile 2009 DIABETES Valvular Disease HEART FAILURE SURGERY Cardiomyopathies Delayed Primary PTCA Myocardial Infarction Hypertension End Stage HF (10%)

3. Paolo FerrazziRozzano 17 aprile 2009 HTx 344/yrs VAD 30/yrs Conventional Surgery n° ? 25.000 End Stage 250.000 Heart failure ISCHEMIC HYPERTENSIVE VALVULAR IDIOPATIC Surgical Treatment of Heart Failure in Italy

4. Paolo FerrazziRozzano 17 aprile 2009 ICM worse results then DCM!!! ICM worse results then DCM!!! Heart Failure Surgical Options Heart Transplant VAD (recovery, continuous flow) Mitral annuloplasty

5. Paolo FerrazziRozzano 17 aprile 2009 Sugical Treatment of Heart Failure Substitutive Surgery –Transplantation: shortage of donors –VAD: cost, management, complications Reconstructive Surgery –SVR + CABG (STICH Results) –No basic research

6. Paolo FerrazziRozzano 17 aprile 2009

7. Paolo FerrazziRozzano 17 aprile 2009 STICH Results Comparison CABG vs SVR + CABG instead of HTx vs SVR + CABG in a sub-class of patients –VO 2 max and right catheterization not available In more experienced Centers: exclusion from randomization of patients with a strong indication to SVR Regional differences in surgical results –SVR long tradition? Inadeguate mean ESV reduction (-19%) in SVR patients Personal Opinions

8. Paolo FerrazziRozzano 17 aprile 2009

9. Paolo FerrazziRozzano 17 aprile 2009 SVR & diastolic function Animal study Clinical follow-up Mathematical model Post-op ECHO study DIASTOLIC FUNCTION SYSTOLIC FUNCTION Systolic improvement is paid by some diastolic dysfunction … presented for the first time in 2000!

10. Paolo FerrazziRozzano 17 aprile 2009 Passive Diastolic Function ….a black hole in echocardiography Systolic FunctionEarly DiastoleLate Diastole Fractional shortening Vcf Stress-corrected Vcf Ejection fraction Tei index Strain and strain rate TDI S-wave E/A ratio DT msec IVRT msec PV S/D ratio TDI-E/E

11. Paolo FerrazziRozzano 17 aprile 2009 Clinical Research SVR ….. thinking to diastolic function: The horseshoe repair Potential Advantages Horseshoe repair Volume EqD Eccentricity index Stroke volume Late diastolic function Ferrazzi, et al JTCVS 2008

12. Paolo FerrazziRozzano 17 aprile 2009 Apr 2005 - Dec 2008 n pts 34 Age (mean)59.07±8.9 Mitral repair 21 pts (61%) Follow-up (mean)16±10.3 mo Hosp. Mortality2 pts (5.8%) Fu mortality2* *1 pneumonia after 4 mo and 1 sudden death after 2 mo SVR – HORSESHOE REPAIR 84.1±11.699.5±13.4Ø Longitudinale (mm) 0.000150.3±7.764.2±5.5Ø Equatoriale (mm) 0.0001 96.8±29.3 (- 44%) 174.0±56.3 VTSV sn (ml) 0.0001 1.3±0.5 3.0±0.2 NYHA P-value Follow-up Preop 0.000140.0±8.2 27.1±5.7 FE (%) 0.002

13. Paolo FerrazziRozzano 17 aprile 2009 Experimental Research The Endoventricular Elastic Devices Restore the elasticity of the dilatated heart Reduce left ventricle volume Store wasted energy during the diastolic phase Give the stored energy back during the sistolic phase Ferrazzi, et al J Cardiovasc Med 2006

14. Paolo FerrazziRozzano 17 aprile 2009

15. Paolo FerrazziRozzano 17 aprile 2009 COMPLEX PATHOPHYSIOLOGICAL MECHANISM OF FUNCTIONAL MITRAL INCOMPETENCE Ischemic Heart Failure VALVE PAPILLARY MUSCLES LEFT VENTRICLE

16. Paolo FerrazziRozzano 17 aprile 2009

17. Paolo FerrazziRozzano 17 aprile 2009 Work in progress...

18. Paolo FerrazziRozzano 17 aprile 2009 Current Practice: One size fits all ! Cardiac surgery Surgical TrialPersonalized surgery

19. Paolo FerrazziRozzano 17 aprile 2009 HEART FAILURE GENOMICS & BIOLOGY ANATOMY & GEOMETRY PHYSIOLOGY BIO ENGINEERING Heart Failure: back to surgical research...