paolo ferrazzirozzano 17 aprile 2009 paolo ferrazzi dipartimento cardiovascolare ospedali riuniti...

Paolo FerrazziRozzano 17 aprile 2009

Paolo FerrazziDipartimento Cardiovascolare

Ospedali Riuniti Bergamo

Ninth International SymposiumNinth International Symposium HEART FAILURE & Co.HEART FAILURE & Co.

Rozzano ,April 17, 2009Rozzano ,April 17, 2009

What Can the Surgeon Do to Avoid

Heart Replacement?


DIABETES

ValvularDisease

HEART

FAILURE

SURGERY

Cardiomyopathies

DelayedPrimaryPTCA

MyocardialInfarction

Hypertension

End Stage HF(10%)


HTx

344/yrs

VAD 30/yrs

Conventional Surgery n° ?

25.000 End Stage

250.000 Heart failure

60%11%

15%

14%

ISCHEMIC

HYPERTENSIVE

VALVULAR

IDIOPATIC

Surgical Treatment of Heart Failure in Italy


ICM worse results then DCM!!!ICM worse results then DCM!!!

Heart Failure Surgical Options

Heart Transplant VAD (recovery, continuous flow) Mitral annuloplasty


Sugical Treatment of Heart Failure

Substitutive Surgery– Transplantation: shortage of donors– VAD: cost, management,

complications

Reconstructive Surgery– SVR + CABG (STICH Results)– No basic research


STICH Results

Comparison CABG vs SVR + CABG instead of HTx vs SVR + CABG in a sub-class of patients– VO2max 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


SVR & diastolic function

Animal study Clinical follow-up

Mathematical model

Post-op ECHO study

DIASTOLICFUNCTION

SYSTOLICFUNCTION

Systolic improvement is paid by some diastolic dysfunction

… presented for the first time in 2000!


Passive Diastolic Function ….a black hole in echocardiography

Systolic Function Early Diastole Late 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’


Clinical ResearchSVR ….. thinking to diastolic function:

The “horseshoe repair”

Potential Advantages Horseshoe repair

Volume EqD Eccentricity index Stroke volume Late diastolic function

Ferrazzi, et al JTCVS 2008Ferrazzi, et al JTCVS 2008


Apr 2005 - Dec 2008

n pts 34 Age (mean) 59.07±8.9Mitral repair 21 pts

(61%)Follow-up (mean) 16±10.3

moHosp. Mortality 2 pts

(5.8%)Fu mortality 2**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)0.000196.8±29.3 (-44%)174.0±56.3VTSV sn (ml)

0.00011.3±0.53.0±0.2NYHA

P-valueFollow-upPreop

0.000140.0±8.227.1±5.7FE (%)

0.002


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 2006Ferrazzi, et al J Cardiovasc Med 2006


COMPLEX PATHOPHYSIOLOGICAL MECHANISM OF FUNCTIONAL MITRAL

INCOMPETENCE

Ischemic Heart Failure

VALVE PAPILLARY MUSCLES LEFT VENTRICLE


Work in progress...


Current Practice:One size fits all !

Cardiac surgery

Surgical Trial Personalized surgery


HEART FAILURE

GENOMICS&

BIOLOGY

ANATOMY&

GEOMETRY

PHYSIOLOGY

BIOENGINEERING

Heart Failure: back to surgical research...

paolo ferrazzirozzano 17 aprile 2009 paolo ferrazzi dipartimento cardiovascolare ospedali riuniti...

Documents

paolo ferrazzirozzano

basic research slide

dilatated heart

heart replacement

diastolic function ferrazzi

clinical research svr

mo svr horseshoe repair

passive diastolic function