Surgical solution for failing heart


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Surgical solution for failing heart

  1. 1. SURGERY FOR FAILING HEART Dr.Harilal.V.Nambiar MS, MCh(CTVS), FIACS Sr. Consultant CT Surgeon Baby Memorial Hospital Calicut
  2. 2. Introduction Heart failure is a global term for the physiological state in which cardiac output is insufficient for the body's needs. It is a condition in which there is problem with the structure or function of the heart and it impairs the ability to supply sufficient blood flow to meet the body's needs.
  3. 3.  Incidence  Heart failure affects nearly 5.7 million people  Roughly 670,000 people are diagnosed with heart failure each year.  It is the leading cause of hospitalization in people older than 65.  1 in every 5 people will develop heart failure .
  4. 4. Incidence (per year) Prevalence Hospitalization Cost • 550,000 new diagnoses • 300,000 deaths • 1-2% of population (5 million ) •6 days (average) 50% re - hospitalized within 6 months •1-2% total health care spending $ 35 billion
  5. 5. Mortality  80% of men and 70% of women with less than 65 years of age and HF will die within 8 years  Up to 42% of patients die of HF within 5 years of hospitalization of HF.  Sudden cardiac death is 6 to 9 times more likely in a HF patient as compared to the general population.
  6. 6. Clinical Types  Acute heart failure: A sudden change in heart function related to some new event that has caused damage to the heart.  Chronic heart failure: A gradual decline of heart function over a period of time. Often the body compensates slowly for the loss of heart function.
  7. 7. Causes Acute Heart Failure  Myocardial Infarction  Pulmonary Embolism  Myocarditis  Post-partum Cardiomyopathy  Acute worsening of CHF  Acute HTx Rejection  Trauma Chronic Heart Failure  Coronary artery disease  Idiopathic cardiomyopathy  Peripartum cardiomyopathy  Dilated cardiomyopathy  Ischemic cardiomyopathy  Valvular disease  Congenital heart disease
  8. 8. NYHA Functional Classification Class Description I No limitation of physical activity - ordinary physical activity doesn't cause tiredness, heart palpitations, or shortness of breath II (Mild) Slight limitation of physical activity, comfortable at rest, but ordinary physical activity results in tiredness, heart palpitations, or shortness of breath III (Moderate) Marked or noticeable limitations of physical activity, comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath IV (Severe) Severe limitation of physical activity, unable to carry out any physical activity without discomfort. Symptoms also present at rest. If any physical activity is undertaken, discomfort increases.
  9. 9. AHA/ACC 2009 - Staging System of Heart Stage Description Examples A People at high risk for developing heart failure but without structural heart disease or symptoms of heart failure. Encompasses “pre heart failure” where intervention with management can overt Progression to symptoms CAD (coronary artery disease), diabetes, hypertension, metabolic syndrome, obesity, using cardiotoxins or alcohol, family history of cardiomyopathy, cerebrovascular accident (CVA), personal history of rheumatic fever B People with structural heart disease but without signs and symptoms of heart failure NYHA Class I Left ventricular hypertrophy (LVH) or reduced left ventricular ejection fraction (LVEF), asymptomatic valvular heart disease, previous MI C People with structural heart disease with prior or current symptoms of heart failure NYHA Class II and III Known structural heart disease with dyspnea, fatigue, inability to exercise D People who have advanced heart failure and severe symptoms difficult to manage with standard treatment NYHA Class IV Marked symptoms at rest despite maximal medical therapy, with recurrent hospitalizations
  10. 10. Acute Heart Failure – Rx Options  IABP  ECMO  TANDEM HEART  IMPELLA
  11. 11. IABP • Device placed via the femoral artery (in the leg) to increase heart blood flow.
  12. 12. • Pros: – Can be placed and removed by a catheter. – Will allow increased heart and brain blood flow – Reduce the after load – Reduce myocardial O2 demand • Cons: – Lack of active cardiac support – Need some residual LV function – Less effective in arrhythmias
  13. 13. ECMO • Blood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium, – Oxygenate – Extract carbon dioxide • Blood is then returned back to the body either peripherally via a femoral artery or centrally via the ascending aorta.
  14. 14. • Full cardiopulmonary bypass • Provides body with oxygenated blood • Provides body with full cardiac output • Allows heart and lungs to rest as body recovers from injury and insult
  15. 15. Pros: Can be placed percutaneously anywhere Provides full heart and lung support Cons: Must be removed surgically Need trained staff to monitor and adjust 24 hrs/day while on support Have increased bleeding and vascular complications
  16. 16.  Centrifugal flow pump placed percutaneously  Designed to augment left ventricular output and rest left ventricle  Can augment cardiac output up to 5 LPM Tandem Heart
  17. 17. Levitronix Centrimag • Newer generation magnetic levitation Centifugal pump rotates in contact-free manner. • Increased durability. • Minimal thrombus and hemolysis
  18. 18. No evidence to show superiority to conventional therapy. •Theoretical advantage to allowing the left ventricle to rest and provide the body with support. •No mechanism to deal with right ventricular failure. •Trial starting now to determine efficacy versus other devices
  19. 19. Pros: - Can fully augment LV output. - Placed & removed percutaneously Cons: - Must have skilled person to place the cannula trans- septaly. - Cannula position is difficult to control and can migrate
  20. 20. Impella  Axial flow pump  Miniaturized impellar pump in catheter  Helical catheter tip placed across aortic valve and left ventricle  Percutaneous or direct placement  Flow 4.5L/min  Bridge to recovery
  21. 21. Impella RP • Catheter-based percutaneous VAD (22 Fr pump mounted on a 11 Fr catheter) • Treatment: Right ventricular dysfunction • Flow: > 4 L/min • Duration of support: up to 14 days • Pump Inflow: Inferior Vena Cava (IVC) Pump Outflow: Pulmonary Artery (PA)
  22. 22.  Advantages  Small pump  Percutaneously placed  Easy removal  No need for trans septal puncture  Disadvantages  Hemolysis  Difficulty of placement in PVD
  24. 24. CABG  LVEF ≤ 0.35  CAD suitable for CABG anatomically.  Left main CAD ≥ 50% stenosis  Class III angina or greater  Viable(Hibernating) myocardium(5/12 segments) – Cardiac MRI/Dobutamine stress echo
  25. 25.  In patients with HF, LVD and CAD amenable to surgical revascularization, CABG added to intensive medical therapy (MED) will decrease all-cause mortality compared to MED alone.  3% (CABG+Med) Vs 31%(Med alone)
  26. 26. Benefits  Reduced mortality rates  Improved NYHA classification  Favorable alteration of LV geometry  Increased LVEFs
  27. 27. Valve Surgery AVR indicated in  Symptomatic HF in sev AS/AR  Asymptomatic patients with sev AS/AR & EF <50%
  28. 28.  LV contractile reserve assessed by Dobutamine stress echo.  Distinguish heart failure due to valvar disease or cardiomyopathy – Ischemic / restrictive.  If contractile reserve present and a valvar problem will benefit from Sx.  No contractile reserve / Cardiomyopathy treated with  Aorto apical conduit/LVAD/Percutaneous valve/HTx
  29. 29. Mitral Valve Ischemic MR • Ischemic MR is a ventricular problem. • Papillary muscle rupture. • Stretching/tenting of mitral leaflet • Alteration in LV geometry, annular dilatation contributes to volume overload, ↑ wall tension, exacerbate failure
  30. 30.  Ischemic MR • Sx will reverse the cycle of excess ventricular volume, ventricular unloading and promoting myocardial remodeling.  Annuloplasty + CABG with chordal shortening/re location  Mitral valve replacement with chordal preservation.  Isolated MVR not recommended. Organic MR  Early Sx before LV dysfunction sets in(EF>50%)  Outcomes are poor with EF<30%
  31. 31. SURGICAL VENTRICULAR RESTORATION History of procedures  Ischemic - Batista - Left ventricular aneurysmectomy  Non ischemic - Cardiomyoplasty Current LV Reconstructive procedures  Ischemic - Dor procedure  Non-ischemic - Acorn Mesh - Myosplint
  32. 32. SVR for Ischemic Cardiomyopathy  Systolic HF leads to an enlarged LV volume to maintain stroke volume  This leads to increase in wall stress due to Laplace's law stress = pressure x radius ÷ 2 x wall thickness  The ventricular geometry becomes less ellipsoid and more spherical leading to progression of left ventricular dysfunction and worsening heart failure.
  33. 33.  LV size was a predictor of sudden cardiac death  In the 1990’s studies showed a relationship between LV size and Mortality  LV’s > 4 cm/m2 had a 2 year survival of 49% compared to 75% if < 4 cm/m2
  34. 34.  Removing or excluding portions of the dysfunctional myocardium returns the left ventricular cavity to a smaller chamber with more normal geometry  This should improve cardiac work efficiency and theoretically should improve heart failure symptoms.  Ideally it would also translate into prolonged survival
  35. 35. • Removal of a section of the left ventricular free wall, between both papillary muscles and extending from the apex to the mitral annulus • Remaining free edges were re- -approximated and stitched together • Mitral valve and subvalvular apparatus were either preserved, repaired, or replaced
  36. 36. Partial Left Ventriculectomy (Batista Operation)  Initial experience with the Batista procedure demonstrated an initial increase in LVEF, reduction in heart size, and improvement in clinical functional status  However, of 120 patients Batista reported a 22% operative mortality and 2 year survival of 55%.
  37. 37.  Late fatal arrhythmias plagued this procedure, forcing the use of concomitant implantable defibrillators  Therefore the Batista procedure has fallen out of favor and is no longer considered to be an appropriate option
  38. 38. Left ventricular aneurysmectomy  The first successful surgical correction of an LV aneurysm occurred in 1957 by Dr. Bailey  Done without off cardiac bypass by placing a clamp on the base of an aneurysm and passing suture beneath allowing excision of the aneurysm.
  39. 39.  Dr. Denton Cooley performed a resection of an LV aneurysm one year later on bypass which remained the standard for nearly 30 years
  40. 40. Left ventricular aneurysmectomy  A 2004 ACC/AHA task force concluded that it is reasonable (class IIa recommendation) to consider Aneurysmectomy +CABG, in patients with a left ventricular aneurysm in the setting of an acute MI who have intractable ventricular arrhythmias and/or heart failure unresponsive to medical and catheter-based therapy
  41. 41. LV Reconstruction for Ischemic Cardiomyopathy  Dor procedure also called endo ventricular circular patch plasty (EVCPP), is an approach to surgical reconstruction in the setting of post infarction aneurysm formation first reported in 1985  Advantage to aneurysmectomy is in an attempt to restore left ventricular geometry
  42. 42. Indications  Anteroseptal MI, with dilated left ventricle (end- diastolic volume index >100 mL/m2)  Depressed LVEF (20%)  Left ventricular regional dyskinesis or akinesis >30 % of the ventricular perimeter  Either symptoms of angina, heart failure, or arrhythmias or inducible ischemia.
  43. 43. Relative contraindications  Systolic pulmonary artery pressure >60 mmHg  Severe right ventricular dysfunction  Regional dyskinesis or akinesis without dilation of the ventricle
  44. 44. Dor procedure for Ischemic Cardiomyopathy
  45. 45. 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
  46. 46. SVR - Dor Procedure
  47. 47. SVR for non ischemic Cardiomyopathy  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.  Principle is based on the fact that skeletal muscle can be trained to be fatigue resistant.
  48. 48.  Carpentier and Chachques peformed the first successful surgery on a human in 1985
  49. 49.  Symptomatic improvement occurred after cardiomyoplasty  Mechanism for improvement is unclear  Pacemaker synchronization was critical for obtaining optimal improvement.
  50. 50.  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
  51. 51. SVR for Non-Ischemic Cardiomyopathy(new options)  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 end- diastolic dimension, and quality of life
  52. 52. CorCap Cardiac Support Device The CorCap is designed to:  Provide end-diastolic ventricular support to reduce wall stress and myocardial stretch  Negate the stimuli for ventricular remodeling and promote myocardial reverse remodeling  Reverse progressive dilation and improve cardiac function and patient functional status
  53. 53.  Study of 27 pt NYHA class went from mean 2.5 to 1.7  After one year, there is no evidence of constriction and coronary blood flow reserve remained normal
  54. 54.  Myosplint  Two epicardial pads and a tension wire  Two pads on the surface of the heart  Wire passes through the ventricle  Placed under tension to to create a bi-lobular shape
  55. 55.  NYHA functional class went from 3.0 +/- 0.3 at baseline to 2.1 +/- 0.7 at 6 months (p = 0.001).  The LV ejection fraction significantly increased in the Myosplint alone group (from 17.1 +/- 4.0% at baseline to 23.1 +/- 7.2% at 6 months  No serious device-related adverse events or device failures were observed
  56. 56. Ventricular assist devices  Pulsatile  Heart mate XVE  Abiomed 5000  Thoratec VAD  Non pulsatile  Jarvik 2000  Heart mate II  Heart ware
  57. 57. Heart mate XVE  Pneumatic or vented electric plates  Textured internal surfaces  Only left-sided support  Flows 10L/min  Bridge to transplant  First device to be approved for destination therapy  Need BSA>1.5  Limited durability: half life 18 months  Infection risk with percutaneous drive line
  58. 58. Abiomed 5000 Extracorporeal Pneumatic pulsatile pumps Uni- or biventricular support Bridge to transplant Easy to insert and operate so used in community hospitals Flows 6L/min
  59. 59. Thoratec VAD (pVAD/iVAD)  Pneumatic, external(pVAD) or internal (iVAD), pulsatile pump(s)  right-, left-, or bi-ventricular support (RVAD/LVAD/BiVAD)  up to ~7.2 lpm flow  Short- to medium-term use (up to ~1-2 years)  bridge to recovery  bridge to transplant  hospital discharge possible iVAD pVAD
  60. 60. Jarvik 2000 LVAD  Axial-flow (non-pulsatile) pump  electric, intra-ventricular  left heart support only  Speed: 8000-12000 rpm  flow: ~3-5 lpm  Medium- to long-term therapy (months to years)  bridge to transplant (investigational)
  61. 61. Jarvik 2000 LVAD
  62. 62. Heart Mate II • Continuous axial flow pump • Connects LV apex to Aorta • Bypasses blood flow from the left ventricle • Only has exteriorized driveline connected to external monitor and power source • Must be placed surgically • Can be used as bridge to transplant or as destination therapy
  63. 63. Heart Mate II…  Pros:  Excellent flow device  Very durable  Easily implantable  Has excellent long term efficacy & data  Cons:  Difficult to explant  Need chronic anticoagulation  Device does have defined lifespan  Patient must be of a certain size to accommodate device
  64. 64. Heart ware • Continuous axial flow pump • Connects LV apex to Aorta • Bypasses blood flow from the left ventricle • Only has exteriorized driveline connected to external monitor and power source • Must be placed surgically • Can be used as bridge to transplant or as destination therapy • Small device can be placed in any body habitus • Can be used for biventricular long- term support • Currently on trial
  65. 65. Device complications  Early  Bleeding  Right sided heart failure  Progressive multi organ system failure  Arrhythmias  Late  Infection  Thrombo embolism  Failure of device
  66. 66. Total Artificial Heart  An artificial heart is a mechanical device that replaces the heart. Artificial hearts are typically used in order to bridge the time to heart transplant, or to permanently replace the heart in case transplantation is impossible.
  67. 67. Indications Bridge to Tx  Patient at risk of imminent death from non reversible bi-ventricular failure  Post MI-VSR  Intractable arrhythmias/ RV failure Destination Rx  Patients unfit for Tx-Malignancy, Systemic disease(amylodosis)
  68. 68. Types of Artificial Heart Jarvik 7 Robert Jarvik, MD is widely known as the inventor of the first successful permanent artificial heart, the Jarvik 7. In 1982, the first implantation of the Jarvik 7 in patient Barney Clark caught the attention of media around the world.
  69. 69. Syncardia - Cradiowest TAH
  70. 70. Types of Artificial Heart AbioCor The AbioCor is the artificial heart is developed by Abiomed .The AbioCor heart, which is composed of titanium and plastic, connects to four locations: Right atrium Left atrium Aorta Pulmonary artery
  71. 71. Types of Artificial Heart
  72. 72.  Advantage  No External drive lines  Trans cutaneous transmission of energy  Reduced chance of infection Disadvantage  Large size  Implantable only in 50% men and 20% women
  73. 73. Carmat Bioprosthetic TAH – Carpentier, France 2013  Made of biologic & Synthetic polymers.  It has the shape & Volume of normal heart.  Weight - 900gms(3x of normal heart).  Provided with multiple sensors for optimizing CO in response to various demands.  Powered by lithium battery.  Fits into 75% men & 25% women.  Cost - $200,000(₹ 1,20,00000).
  74. 74. HEART TRANSPLANT  Replacement of the failing heart with a heart from a suitable donor.
  75. 75.  Cardiac transplantation is currently the only established surgical approach (excluding AVR and CABG) for the treatment of refractory HF as listed in the 2005 ACC/AHA heart failure guidelines  Small number of available donor hearts  Inapplicable in older pts or those with comorbid conditions
  76. 76. Class I Indications for Cardiac Transplantation  Cardiogenic shock requiring mechanical assistance.  Refractory heart failure with continuous inotropic infusion.  NYHA functional class 3 and 4 with a poor 12 month prognosis.  Progressive symptoms with maximal therapy.  Severe symptomatic hypertrophic or restrictive cardiomyopathy.  Medically refractory angina with unsuitable anatomy for revascularization.  Life-threatening ventricular arrhythmias despite aggressive medical and device interventions.  Cardiac tumors with low likelihood of metastasis.  Hypoplastic left heart and complex congenital heart disease.
  77. 77. • Patients should receive maximal medical therapy before being considered for transplantation. They should also be considered for alternative surgical therapies including CABG, valve repair / replacement, cardiac septalplasty, etc. • VO2 has been used as a reproducible way to evaluate potential transplant candidates and their long term risk. peak VO2 <10 had the greatest survival benefit.
  78. 78. Contra Indication  Active infection  Active malignancy  Active systemic disease  PVR > 4Wood units  On going drug abuse  Mental instability  Lack of compliance  Age > 65 Years
  79. 79. Procedures Orthotopic Tx  Bi Atrial technique(Shum way)  Bi caval Technique Hetrotopic Tx
  80. 80. Donor Heart Procurement  Median sternotomy.  Cold cardioplegia given one litre.  Heart removed  Kept in Cold University of Wiscosin solution.  Cardiac ischemia time 180 min
  81. 81. Donor allograft preparation for orthotopic heart transplantation. Pulmonary vein orifices joined to form left atrial cuff.
  82. 82.  First suture is placed at the level of the left superior pulmonary vein.
  83. 83.  Implantation of allograft (continued). Left atrial anastomosis.
  84. 84.  Right atrial anastomosis.
  85. 85. •Aortic anastomosis.
  86. 86. • Completed transplant • Pacing wires on donor portion of right atrium and ventricle • Pericardium left open * Orthotopic HTx
  87. 87. Alternative Bicaval Approach • Left atrial anastomosis performed • Separate inferior and superior vena caval anastomosis *
  88. 88. •Bicaval is preferred one today. • described by Lower and colleagues. •Achieves more anatomic position, •Neutralizes potential for atrial enlargement •Less tricuspid regurge •Better hemodynamic performance.
  89. 89. Heterotopic Heart Transplants • Heterotopic heart transplants are indicated in patients with - irreversible pulmonary hypertension or - significant donor-recipient size mismatch.
  90. 90. • Donor allograft preparation for heterotopic heart transplantation.
  91. 91. •Completed Hetrotopic Tx.
  92. 92. Immuno suppression  Cyclosporin  Corticosteroids  Mycophenolate mofetil  FK-506 (tacrolimus):  Antilymphocyte globulin  Muromonab-CD3 (OKT3  Rapamycin
  93. 93. Complications:  Hyperacute Rejection  Acute Cellular Rejection  Vascular (humoral) Rejection  Infection – CMV  Toxoplasma gondii  Pneumocystis carinii  Aspergillus organisms  Malignancy  Hypertension  Dyslipidemia  Tricuspid Regurgitation
  94. 94. Outcome  1 year survival rate 81.8%  5 year survival rate 69.8%  10 year survival rate 50%  Functional status of the patient is excellent
  95. 95. Thank you…The Journey continues…