Transcript Surgical Therapy for Heart Failure

In the name of GOD
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Treatment of End Stage Heart
Failure
Surgical Treatments
Cardiac Resynchronization
Treatment(CRT)
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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
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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,
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pericardium, or an autologous tissue flap
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
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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.
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Cardiomyoplasty
Carpentier peformed the first successful
surgery on a humen in 1985
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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
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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
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LV Reconstruction for Nonischemic 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
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LV Reconstruction for Nonischemic 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 enddiastolic dimension, and
quality of life
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INTRODUCTION
Heart transplantation remains the ultimate
treatment for heart failure
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HEART TRANSPLANTATION
ACTUARIAL SURVIVAL (1982-2000)
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Half-life =9.1 years
Conditional Half-life = 11.6 years
Survival (%)
80
60
N=52,195
40
20
0
0
1
2
3
4
5
6
7
8
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10 11 12 13 14 15 16 17
Years Post-Transplantation
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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)
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Intraaortic Balloon Pump (IABP)
Provides temporary
circulatory assistance
– ↓ Afterload
– Augments aortic
diastolic pressure
Outcomes
– Improved coronary
blood flow
– Improved
perfusion of vital
organs
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Ventricular
Assist
Devices
Ventricular
Assist
Devices
(VADs)
(VADs)
• Indications for VAD therapy
• Postcardiotomy cardiogenic shock
• Bridge to recovery or cardiac
transplantation
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
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Left ventricular assist
device
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Cardiac Resynchronization
Therapy for Heart Failure
Patient Selection
and Clinical Outcomes
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CRT-Cardiac Resynchronization
Therapy
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.
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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
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Cardiac Resynchronization
Therapy
Goals
Improve hemodynamics
Improve Quality of Life
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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 IVCD
ECG depicting cardiac resynchronization
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Achieving Cardiac
Resynchronization
Mechanical Goal: Pace Right and Left Ventricles
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
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. 4.
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THANKS FOR YOUR
ATTENTION
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