Surgical management of end stage heart

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SURGICAL MANAGEMENT OF END STAGE HEART Dr. Yousry El-Saied, MD Consultant Cardiothoracic Surgeon, Bisha


Objectives Surgical indications Surgical options LVAD Bridging to transplantation Transplantation


Introduction The surgical options for the end-stage heart failure patient are now numerous and effective. The aim of Surgical Management of Congestive Heart Failure is to bring together the latest clinical, scientific, and investigational surgical approaches to improve the lives of this challenging group of patients.

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“In designing a heart failure management program, it's vitally important to embrace continuity of care, ideally beginning well before the first symptoms appear, to ensure consistent, appropriate treatment throughout the natural course of the disease.” Mariell Jessup, MD, Director, The Heart Failure and Transplantation Program

Surgery for Heart Failure:

Surgery for Heart Failure Re pair Re modeling Re placement

Surgical Options:

Surgical Options Coronary artery bypass grafting (CABG) Mitral valve repair Surgical ventricular restoration (SVR) Restraint devices Ventricular assist devices (VADs) Cardiac transplantation

Coronary Artery Bypass Grafting (CABG):

Coronary Artery Bypass Grafting (CABG) Depends upon myocardial viability and adequacy of target vessels for revascularization. However, most heart failure patients do not have angina and therefore, either echocardiographic or nuclear demonstration of viability and reversible ischemia is necessary before proceeding with CABG.

Coronary Artery Bypass Grafting (CABG):

Coronary Artery Bypass Grafting (CABG) The use of off-pump techniques and beating heart surgery have lessened the morbidity and mortality associated with coronary revascularization in patients with severe left ventricular dysfunction and in marginal patients.

Coronary Artery Bypass Grafting (CABG):

Coronary Artery Bypass Grafting (CABG) The

Mitral Valve Repair:

Mitral Valve Repair Functional and/or ischemic MR is a disease of the left ventricle rather than the mitral valve. Ventricular dilation include dilation of the mitral annulus, apical and lateral displacement of the papillary muscles with tethering of the subvalvular apparatus and mitral leaflets leading to failure of coaptation.

Mitral Valve Repair:

Mitral Valve Repair Numerous surgical techniques have been described to address the annular dilatation, All annular remodeling techniques decrease the anterior-posterior diameter of the annulus enhancing leaflet coaptation.

Mitral Valve Repair:

Mitral Valve Repair Most rings are complete and rigid or semi-rigid. Also in clinical trials is the Coapsys device (Myocor, Inc., Maplegrove, MN), which places bridges on the outside of the ventricle and a tethering strand through the left ventricle to decrease the septal lateral diameter of the mitral annulus.

Surgical Ventricular Restoration (SVR):

Surgical Ventricular Restoration (SVR) In patients with ischemic heart disease and anteroapical dyskinesis or aneuryms , the Dor procedure and modifications by Menicanti have some role. With this technique the left ventricle is opened through the anteroapical scar and a mannequin device is used to size for appropriate right sizing of the left ventricle. A Dacron patch is then sutured the edges of the scar and the left ventricle closed over the Dacron patch. This technique prevents obliteration of the left ventricular cavity, which was a problem with some of the previous ventricular aneurysmectomy techniques.

Left Ventricular Reconstruction Surgery (Dor):

Left Ventricular Reconstruction Surgery ( Dor ) Surgical remodeling of the ventricle, especially when significant ventricular distortion is present, can improve ventricular function and can be performed concomitantly with coronary bypass grafting . This procedure, as modified by Dor , involves decreasing the scar siz by apposing the surrounding viable myocardium directly or through a pericardial patch . By maintaining LV geometry at a lower volume

Left Ventricular Reconstruction Surgery (Dor):

Left Ventricular Reconstruction Surgery ( Dor ) One surgical method for end-stage heart failure for ischemic cardiomyopathy . In the failing heart, the normal elliptical ventricular shape is lost and is replaced by a dilated, spherical muscle or remodeled ventricle. This surgery helps to improve ventricular function by reversing this remodeling of the heart such that the shape of the ventricle subsequently becomes more normal and the mechanics of contraction improve. A recent review of this experience demonstrated survival of 98%, 92%, 90%, and 86% at 30 days, 1, 2, and 3 years respectively.

Ventricular Assist Devices (VADs):

Ventricular Assist Devices (VADs) VADs are used as: B ridge T o R ecovery ( BTR ) B ridge T o T ransplantation ( BTT ) D estination T herapy ( DT ) in patients who are non-transplant candidates either because of age or comorbidity.

Ventricular Assist Devices (VADs):

Ventricular Assist Devices (VADs) The two-year survival was 25% in patients with VADs and 8% with optimal medical management. Improved survival 50% at 12 months and 35% at 24 months.

Short-term LVADs:

Short-term LVADs Centrifugal Pumps Widely available FDA approved Relatively cheap Easy to run Non- pulsatile flow

Bridge To Transplantation:

Bridge To Transplantation HeartMate FDA approved Expensive Very reliable No anticoagulation “Wearable” Outpatient support

Current Newer Generation Devices:

Current Newer Generation Devices Jarvik VAD HeartMate II VAD DeBakey VAD

Total Artificial Heart:

Total Artificial Heart The artificial heart is an orthotopic , biventricular, pneumatic, pulsatile blood pump , it replaces the native ventricles. It is attached to the left and right atrial cuffs with individual “quick connectors” (elastic polyurethane couplers over rigid ventricular valve mounts) that couple to their respective ventricles. Blood passes through this almost imperceptible junction from the atrium, across a 27-mm Medtronic-Hall valve, to the ventricular chamber. The spherical chamber is lined with segmented polyurethane. The outer chamber is a semirigid polyurethane-lined housing that does not move. The inner chamber contains a four-layer polyurethane diaphragm driven by air pressure. The diaphragm moves toward a rigid plastic wall as the ventricle fills with blood in diastole and toward a 25-mm Medtronic-Hall outflow valve in systole, ejecting about 55 to 60 cc per beat. Blood flows through the outflow valves into woven Dacron conduits to the respective great vessels. Dacron-covered drivelines exit through tunnels in the left epigastrium and connect to a driver console. This console contains a backup driver, 304 Surgical Management of Congestive Heart Failure . Drawing to scale of the CardioWest TAH and console. multiple alarms, an internal compressed air supply, and a laptop monitor. The monitor provides beat-to-beat monitoring of ventricular filling, ejection pressure, heart rate, cardiac output on both the left and right sides, and trend monitoring of cardiac output . The console is mobile within the hospital, allowing patients to attend daily cardiac rehabilitation classes and to ambulate outside. There are at least two portable consoles under development that are compatible with out-of-hospital life. The company plans to use these consoles once commercial approval for the device and large console have been obtained in the United States.

Total Artificial Heart:

Total Artificial Heart

Restraint Devices:

Restraint Devices A mesh-like cardiac support device, Acorn CorCap (Acorn Cardiovascular, St. Paul, MN), has been introduced with the purpose of providing end diastolic support and reducing the mechanical stress to cause reverse cardiac remodeling. The inital trial of 130 patients was completed, but did not receive FDA Panel approval. Post-hoc subgroup analysis, however, appears to demonstrate some benefit in those patients with moderate left ventricular dysfunction by preventing further ventricle dilation.

Critical Clinical Issue:

Critical Clinical Issue Can devices be used as a long- term “destination therapy” for patients with ESHD?


Innovation Research into new methods of treatment

Acorn Corcap™ :

Acorn Corcap ™ Acorn CorCap ™ device : The Acorn CorCap ® is a mesh-like polyester “jacket” that is surgically wrapped around a dilated left ventricle to help restore an enlarged heart to a more normal size and shape. Placement of the Acorn CorCap ® can be performed during other cardiac procedures. The Cleveland Clinic was integrally involved in a world-wide randomized trial utilizing this device.

Implantable Hemodynamic Monitor in Patients with Heart Failure :

Implantable Hemodynamic Monitor in Patients with Heart Failure The HeartSensor ® is similar in size to a pacemaker and measures critical clinical factors such as intracardiac pressure. Daily pressure readings are conducted via home monitoring devices and the data is transferred over a phone line to the physician. The HeartSensor ® may help physicians to better manage patients with heart failure. Medications can be adjusted as necessary, and the device serves as an early warning before physical symptoms are manifested.

Stem Cell Research :

Stem Cell Research Stem cells are naturally recruited to the site of a myocardial infarction (heart attack) for up to five days following the event, but are not recruited days or weeks later, even when stem cells are mobilized in the bloodstream. Marc S. Penn, M.D., Ph.D., has pioneered the development of Stromal Cell-Derived Factor 1 (SDF-1). Autologous skeletal myoblasts are modified to over-express SDF-1 and are then transplanted in the infarct zone (damaged area of the heart muscle) eight weeks after a heart attack. Mobilized stem cells are then “homed” to the area of the infarct and form new blood vessel tissue.

AlloMap™ Molecular Expression Testing:

AlloMap ™ Molecular Expression Testing The Cleveland Clinic Heart Center was one of eight leading transplant centers involved in the Cardiac Allograft Rejection Gene Expression Observational (CARGO) study to evaluate peripheral blood gene expression for cardiac transplantation acute rejection management. AlloMap testing is a new blood sample based test developed to manage the complex immunologic questions posed by cardiac transplant patients

Heart transplantation:

Heart transplantation

Cardiac Transplantation:

Cardiac Transplantation Cardiac transplantation has become the routine last option in appropriate patients with end stage cardiomyopathy . Transplant is still limited by donor availability and the number of transplants performed in the United States has remained stable at approximately 2,500 annually. Appropriate candidates include those patients who are under age 65 (70 with nonischemic cardiomyopathy ). Approximately one half of transplants are done for ischemic cardiomyopathy and the other half for nonischemic patients. One-year survival is greater than 90% and 50% survival is 9.6 years.

Contraindications to Heart Transplantation:

Contraindications to Heart Transplantation Absolute contraindications Current malignancy other than skin cancer Hepatatis B or C infection with active hepatitis AIDS (acquired immunodeficiency syndrome) Fixed pulmonary hypertension Relative contraindications Age over 65 years Diabetes mellitus with end-organ damage Significant renal, liver, or lung disease Severe peripheral or carotid vascular disease or abdominal aortic aneurysm HIV infection Hepatitis B or C infection Previously treated malignancy other than skin cancer Reversible pulmonary hypertension Recent pulmonary embolus Active peptic ulcer disease Infiltrative myocardial disease Collagen vascular disease Major psychiatric disorder History of persistent noncompliance with medical care Drug, alcohol, or tobacco addiction

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THANK YOU Dr. Yousry El-Saied