MSN PAVAN KUMAR,DMNIMS,Hyderabad,India.

SURGICAL MANAGEMENT OF HEART FAILURE

1. Coronary artery revascularisation2. Valve surgery3. Left ventricular reconstruction4. Passive cardiac support devices5. LV Assist devices6. Cardiac transplantation

Coronary Artery Revascularisation

Ischemic cardiomyopathyDysfunction arising d/t occlusion of coronary arteries.Most common cause of heart failure in clinical trials.3 inter related processes - stunning , hibernation,

cell death.Selection of patients.Benefits – improvement in LVEF , symptomatic

improvement , survival benefit.Risks Guidelines at present

Selection of patients :Several clinical factors play a major role in the decision-

making,1. The presence of angina, 2. The severity of heart failure symptoms, 3. LV dimensions.4. The adequacy of target vessels for revascularization

and 5. The extent of jeopardized but still viable

myocardium

Coronary Artery Revascularisation

Significant mortality and morbidity benefit occur after coronary revascularisation when at least 25%

of myocardium is viableArend F.L. Schinkel et al. JNM 2007

Benefits : Improvement in LVEF :An average improvement in LVEF of 8 to 10 percent is

likely to occur following coronary artery revascularization.

Improvement is seen in pts with 1. >25% viable myocardium2. < End systolic volume of 130ml3. Normal LV geometry

Improvement continues 6 -12 months after surgery

Coronary Artery Revascularisation

Arend F.L. Schinkel et al. JNM 2007De Bonis et alSurgery insight Nat Clin Pract Cardiovasc Med 2006

Benefits : improvement in symptoms:

Pagano D, Bonser RS, Camici PG:

Myocardial revascularization for the

treatment of post-ischemic heart failure. Curr Opin Cardiol 1999

Significant improvement in functional capacity following revascularization, as reflected by a 34 % increase in exercise capacity from 5.6 to 7.5 METs.

Coronary Artery Revascularisation

Symptom free

1 year 5 year

Angina 98% 81%

Heart failure

78% 47%

Benefits : improvement in survival:No RCT was available untill recently DUKEs database has compared CABG vs MEDICAL

over 25 years

Coronary Artery Revascularisation

Years CABG MEDICAL

1 83% 74%

5 61% 37%

10 42% 13%

SURVIVAL OF PATIENTS(P<0.0001)

O'Connor CM et al: A 25-year experience from the Duke Cardiovascular Disease Databank. Am J Cardiol 90:101, 2002

Benefits : Improvement in survival:RCT – STICH ( Surgical Treatment of Ischemic Heart Failure).

Coronary Artery Revascularisation

Eric J. Velazquez et al Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction N Engl J Med 2011

Benefits : Improvement in survival:RCT – STICH ( Surgical Treatment of Ischemic

Heart Failure).

Coronary Artery Revascularisation

In patients randomized to STICH, there was no statistically significant difference in all-cause mortality between medical therapy alone and medical therapy with CABG

Medical therapy with CABG reduces cardiovascular mortality and morbidity compared to medical therapy alone

When randomized to CABG, patients are exposed to an early risk

Benefits : Improvement in survival:RCT – STICH ( Surgical Treatment of IsChemic

Heart Failure).

Coronary Artery Revascularisation

Eric J. Velazquez et al Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction N Engl J Med 2011

Risks :Perioperative risk in patients with severe LVD

range from 2 to 10%.Risk depends up on

1. Availability of targets2. Viability3. RV dysfunction4. NYHA class 5. Increased LVEDP6. Advanced age7. Associated PAD/STROKE8. COPD

Coronary Artery Revascularisation

Pocar et al.CABG for ischemic cardiomyopathy ATS 2007Hillis et al.outcome of patients in low EF after CABG Circulation 2006

Guideline : (ACC/AHA) CABG in pts with poor LV functionCLASS 1 : LMCA or its equivalentsCLASS 2a : viable non contracting muscleCLASS 3 : with out evidence of ischemia and

viability

Coronary Artery Revascularisation

Hunt SA, et al: ACC/AHA 2009 : Circulation 2009 Rx for heart failureEagle KA, et al: ACC/AHA 1999: Circulation 1999 Rx by CABG

Valvular Surgery

1. Valvular heart disease that lead to LV dysfunction

2. Valvular dysfunction secondary to primary cardiomyopathy

Mitral valve :MR is commonly observed

in pts with poor prognosis and independent risk factor for poor outcome

Ischemic / non ischemic MRBenefits / risksCurrent guidelines

Valvular Surgery Valvular dysfunction– Mitral Valve Surgery.

Valvular Surgery Valvular dysfunction– Mitral Valve Surgery .

Non ischemic MR :Conventional teaching is surgical correction of MR

is associated with prohibitive operative mortalityStudies that proved against the tradition are

BOLLING , MILLER , BISHAY , ACORN (ACKER et al.)Ischemic MR:BAX , FOTTOUCH , ACKER et al showed that mitral

valve repair showed significant benefit . No randominized studies comparing mitral valve

repair from medical therapy is available

Valvular Surgery Valvular dysfunction– Mitral Valve Surgery

ACORN TRIAL :Non randominized ,30 centres , 193 pts , on medical therapy was

done to evaluate safety and efficacy of MVR + CorCop cardiac support device.

Valvular Surgery Valvular dysfunction– Mitral Valve Surgery – Benefits .

Acker MA, et al: Mitral valve surgery in heart failure: JTCS 2006

Change was also noted in MR , NYHA class .

Mortality:In non ischemic MR mortality from various studies

ranged from 1.6%(ACORN trial) to 5%(Bolling study).In Ischemic MR mortality was less than 5%Recurrence :Intial results showing recurrence were around 30-

40%.later on results showed to be recurrence of 10%.(recurrence rates can be deceased by using non flexible and undersized rings).

Valvular Surgery Valvular dysfunction– Mitral Valve Surgery –

Risks/Disadvantages .

No current evidence of survival benefit after MR elimination

MVR for pts with LV dysfunction and ≥ moderate MR may be appropriate for 1. Pts undergoing CABG 2. Pts with dilated cardiomyopathy who remain

symptomatic despite optimal medical therapyACC/AHA 2006 and ESC 2007 suggest that mitral

annuloplasty with an undersized rigid annuloplasty is beneficial.

Valvular Surgery

Valvular dysfunction– Mitral Valve Surgery – Guidelines.

Valvular Surgery Valvular dysfunction– Aortic Valve Surgery – Aortic

Stenosis.

Pereira JJ, et al: Survival after AVR for severe AS with low transvalvular gradients and severe LVD. JACC 2002

Valvular Surgery Valvular dysfunction– Aortic Valve Surgery – Aortic

Stenosis.82%

15%

78%

41%

Although operative mortality has been high in patients with AR and LVD historically , cleveland clinic has indicated that patients with pure AR oerative mortality has been same low since 1985.

In this series there was regresion in LV mass and improvement in LV volume

Late survival has not been as good as pts with normal LV function

Valvular Surgery Valvular dysfunction– Aortic Valve Surgery – Aortic

Regurgitation.

Bhudia SK et al. improved outcomes after AVR in AR with LVD JACC 2007

ACC/AHA guidelines:

Aortic Stenosis :AVR is indicated in pts with true severe aortic

stenosis with LVD with good contractile reserve(class I). With out good contractile reserve???

Aortic Regurgitation: AVR is indicated in pts with severe AR with LVD(class

I).

Valvular Surgery Valvular dysfunction– Aortic Valve Surgery –

Guidelines .

LV Reconstruction

Drug Rx

LVR

LVR

LV Reconstruction

DOR procedure

BATISTA procedure

Overlapping-type left ventriculoplastyYoshiro Matsui,et al. Left Ventricular Reconstruction

for Severely Dilated Heart Ann Thorac Cardiovasc Surg Vol. 14, No. 2 (2008)

The goal of the operation is to reduce end systolic volumes by at least 30% while ensuing that the ventricle in not too small

LV Reconstruction

RESTORE ( Reconstruction Endovascular Surgery Returning Torsion Original Radius Elliptical Shape

To LV)STICH ( Surgical Treatment of Ischemic Heart

Failure)

RESTORE ( Reconstruction Endovascular Surgery Returning Torsion Original Radius Elliptical Shape To LV)

Multicentric registry with 1198 pts of post AMI with heart failure operated between 1998 -2003.

Over all mortality was 5.3% with 1,3,5 year survival rates of 92%,90% and 80%.

LV Reconstruction

Variable Preoperative

Postoperative

LV ESVI 80% 56%

LVEF 29% 39%

NYHA 67%(III) 87%(I – II)

LV Reconstruction

STICH ( Surgical Treatment of Ischemic Heart Failure)

This study tested the hypothesis that adding SVR to CABG in ICMP.

Robert H. Jones et al. CABG with or without SVR NEJM 2009

LV Reconstruction

P=0.84

P=0.70

STICH ( Surgical Treatment of Ischemic Heart Failure)

Robert H. Jones et al. CABG with or without SVR NEJM 2009

Limitations :1.Average % reduction in end systolic volume after

CABG and SVR was 19%2.13% of pts in STICH trial didn’t have an infarct

before the development of LVD .3.Selection bias so that the study didn’t include pts

that clearly benefit from SVR.

LV Reconstruction

STICH ( Surgical Treatment of Ischemic Heart Failure)

STICH trial didn’t prove or disprove the original hypothesis

Current guidelines :Class III Partial left ventriculectomy is not

recommended in patients with nonischemic cardiomyopathy and refractory end-stage HF. (Level of Evidence: C)

LV Reconstruction

Cardiac Support Devices

Cardiomyopastly

Limits ventricular dilation

Reduces LV stress ,with out causing constrictionPrevents LV

remodelling

Starling RC, Surgical treatment of chronic congestive heart failure. In: Mann D, ed. Heart Failure: A Companion to Braunwald's Heart Disease, Philadelphia: WB Saunders; 2003

Cor Cap device (ACORN TRIAL) Ann Thorac Surg 2007

Cardiac Support Devices

The CorCap CSD Rx group had a lower crude mortality rate (25.7%) when compared to the control group (27.0%, risk reduction of 4.8%) but this difference was not significant.

Current Guidelines:As of now current guidelines doesn’t suggest

cardiac support device

Cardiac Support Devices

US FDA doesn’t approve cardiac support device

as of now

IndicationsTypes of devicesDevice selectionEvidenceCurrent guidelines

Ventricular Assist Device

Indications for VAD SupportPatient fails to wean from cardiopulmonary bypass.Extremis with cardiogenic shock or with rapidly

accelerating multisystem organ failure due to acute cardiogenic shock

In chronic heart failureLVEF < 25% VO2 < 14 cc/kg/minNYHA class IV symptoms for 60 d NYHA class III or higher symptoms for 28 d

1. IABP support for 14 d or 2. Two failed attempts to wean inotropes

Ventricular Assist Device

Rose EA,et al. Long-term mechanical left ventricular assistance for end-stage

heart failure. NEJM2001

Shot term devices (bridge to recovery)Pulsatile devices (bridge to transplantation)Axial flow devices (bridge to

transplantation)Total artificial heart (destination therapy)

Ventricular Assist Device

Types Of Devices:

Ventricular Assist Device

They are versatile and may be used as a right ventricular assist device (RVAD) (from right atrium or right ventricle to pulmonary artery [PA]), as an LVAD (from left atrium or LV apex to aorta), or as part of an ECMO.

Require systemic anticoagulation.

Types Of Devices:

The first-generation mechanical circulatory devices used volume displacement to invoke pulsatility.

Pulsatile volume displacement pumps are large in profile, preload dependent, and associated with decreased durability

The HeartMate XVE- textured titanium - pseudo-neointima on which thrombus formation is greatly reduced, thereby decreasing the need for anticoagulation.

Ventricular Assist Device

Types Of Devices:

First-generation pulsatile devices. The HeartMate VE/XVE (A) shown here as the electric version and the Novacor LVAS (B) emerged as the most successful implanted LVADs in the late 1980s and 1990s

Ventricular Assist Device

Types Of Devices:

Continuous-flow axial pumpsThe continuous-flow pumps are smaller, capable of similar

degrees of pumping support (10 liters/min), more durable, and functionally dependent on both preload and afterload.

Although axial flow pumps provide nonpulsatile flow, many patients maintain some native cardiac function during axial pump support and therefore continue to have pulsatile patterns of blood flow unlike with many of the pumps previously described.

Ventricular Assist Device

Types Of Devices:

The second-generation HeartMate II device has an inlet cannula of sintered titanium and a Dacron outflow cannula shown here with bend relief to reduce kinking and injury at resternotomy (A). The system provides mobility for the patient (B).

Ventricular Assist Device

Types Of Devices:

Ventricular Assist Device

Types Of Devices:

Eligible for transplantation as a bride to transplantation with NYHA class IV.

Pts not eligible for transplantation and 30 mortality of >70% -as destination therapy.

PVR > 640 dyne/s/cm–5 ,Dialysis in previous 7 d , Serum creatinine 5 mg/dL , Cirrhosis with total bilirubin 5 mg/Dl, Cytotoxic antibody 10%.

Copeland JG, Smith RG, Arabia FA, et al. Cardiac replacement with a total artificial heart as a bridge to transplantation. N Engl J Med. 2004

Ventricular Assist Device

Survival rates in two trials of LVADs as destination therapy. The curves labeled 2009 are those reported by Slaughter and colleagues; those labeled 2001 were reported for the REMATCH trial.

Fang J: Rise of the machines—left ventricular assist devices as permanent therapy for advanced heart failure. NEJM , 2009

Ventricular Assist Device

Current guidelines:ACC / AHAClass IIa Consideration of an LV assist device as permanent

or “destination” therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy. (Level of Evidence: B)

Ventricular Assist Device

Cardiac Transplantation

IndicationsContraindicationsDonor selection criteriaComplicationsEvidence /outcomesCurrent guidelines

Cardiac TransplantationIndications

Cardiac TransplantationContraindications

Cardiac TransplantationDonor Selection Criteria

Cardiac Transplantation

Cardiac Transplantation

Rejection / immunosupressionInfection

Cardiac Transplantation

Hertz MI, et al: Registry of the International Society for Heart and Lung Transplantation: A quarter century of thoracic transplantation. J Heart Lung Transplant 27:937, 2008

Overall survival at 1 year of 87%By the first year after transplantation surgery, 90% of surviving patients report no functional limitations and approximately 35%

return to work

Outcomes:

Cardiac Transplantation

Time Major cause of death (%death)

< 30 days

Non specific graft failure(41%)

1year Non CMV infection

1-5 years

CMV infections

> 5 years

CAV,late graft failure(31%)Neoplasms(24%)Non CMV infections(10%)

Hertz MI, Aurora P, Christie JD, et al: Registry of the International Society for Heart and Lung Transplantation: A quarter century of thoracic transplantation. J Heart Lung Transplant 2008

Current guidelines: ACC/AHACLASS IReferral for cardiac transplantation in potentially

eligible patients is recommended for patients with refractory end-stage HF. (Level of Evidence: B)

Cardiac Transplantation

Lift is falling then…….????? We never know when and where accidents will happen to us OR people around us. Read on and hope this piece of information may help any of us when things do happen to yourself, our friends and our loved ones.  One day, while in a lift, it suddenly broke down and it was falling from level 13 at a fast speed. Fortunately, I remembered watching a TV program that taught you must quickly press all the buttons for all the levels. Finally, the lift stopped at the 5th level.  When you are facing life and death situations, whatever decisions or actions you make decides your survival. If you are caught in a lift  breakdown, first thought in mind may be 'waiting to die'... But after reading below, things will definitely be different the next time you are caught in a falling lift.  First  - Quickly press all the different levels of buttons in the lift. When the emergency electricity supply is being activated, it will stop the lift from falling further.  Second - Hold on tight to the handle (if there is any).. It is to support your position and prevent you from falling or getting hurt when you lost your balance.  Third - Lean your back and head against the wall forming a straight line. Leaning against the wall is to use it as a support for your back/spine as protection.  Fourth - Bend your knees. Ligament is a flexible, connective tissue.  Thus, the impact of fractured bones will be minimised  during fall.  For everyone, kindly do share  this piece of information with your near and dear ones !! 

Thank You.