surgical management of heart failure
DESCRIPTION
Coronary artery revascularisation Valve surgery Left ventricular reconstruction Passive cardiac support devices LV Assist devices Cardiac transplantationTRANSCRIPT
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
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Thank You.