In the name of GOD 1

Treatment of End Stage Heart Failure Surgical Treatments Cardiac Resynchronization Treatment(CRT) 2

Surgical Treatment of Heart Failure CABGs in ischemic cardiomyopathy Mitral valve repair in patients with dilated cardiomyopathy Surgical Ventricular reconstruction(Dor procedure) Passive Cardiac support Device Heart Transplantation 3

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 4

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 5

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. 6

Carpentier peformed the first successful surgery on a humen in 1985 Cardiomyoplasty 7

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 8

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 9

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 10

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 11

INTRODUCTION Heart transplantation remains the ultimate treatment for heart failure 12

HEART TRANSPLANTATION ACTUARIAL SURVIVAL ( ) N=52,195 Half-life =9.1 years Conditional Half-life = 11.6 years 13

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) 14

Intraaortic Balloon Pump (IABP) Provides temporary circulatory assistance –↓ Afterload –Augments aortic diastolic pressure Outcomes –Improved coronary blood flow –Improved perfusion of vital organs 15

Ventricular Assist Devices (VADs) 16

Left ventricular assist device 17

Cardiac Resynchronization Therapy for Heart Failure Patient Selection and Clinical Outcomes 18

CRT-Cardiac Resynchronization CRT-Cardiac Resynchronization Therapy CRT-Cardiac Resynchronization HOW IT WORKS: Standard implanted pacemakers - equipped with two wires (or "leads") conduct pacing signals to specific regions of heart (usually at positions A and C). Biventricular pacing devices have added a third lead (to position B) that is designed to conduct signals directly into the left ventricle. Combination of all three lead > synchronized pumping of ventricles, inc. efficiency of each beat and pumping more blood on the whole. 19

Ventricular Dysynchrony Abnormal ventricular conduction resulting in a mechanical delay –Wide QRS (IVCD); typically LBBB morphology –Poor systolic function –Impaired diastolic function ECG depicting interventricular conduction delay 20

Cardiac Resynchronization Therapy Goals Improve hemodynamics Improve Quality of Life 21

Cardiac Resynchronization Therapy Cardiac resynchronization, in association with an optimized AV delay, improves hemodynamic performance by forcing the left ventricle to complete contraction and begin relaxation earlier, allowing an increase in ventricular filling time. Coordinate activation of the ventricles and septum. ECG depicting cardiac resynchronization ECG depicting IVCD 22

Transvenous Approach –Standard pacing leads in RA and RV –Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Achieving Cardiac Resynchronization Mechanical Goal: Pace Right and Left Ventricles Cardiac Resynchronization System

MIRACLE Study Population Symptomatic patients with heart failure  18 years of age NYHA Functional Class III or IV QRS duration  130 msec LVEF  35% by echocardiography LVEDD  55 millimeters (echo measure) Stable HF medical regimen for  1-month –ACE-I or substitute, if tolerated –β-blocker - stable regimen for  3-months Abraham WT, et al. Journal of Cardiac Failure 2000; Vol 6 No

THANKS FOR YOUR ATTENTION 25