1. Coronary artery revascularisation2. Valve surgery3. Left ventricular reconstruction4. Passive cardiac support devices5. LV Assist devices6. Cardiac transplantation
Coronary Artery Revascularisation Ischemic cardiomyopathy Dysfunction 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
Coronary Artery Revascularisation 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 Significant mortality and morbidity benefit occur after coronary revascularisation when at least 25% of myocardium is viable Arend F.L. Schinkel et al. JNM 2007
Coronary Artery Revascularisation 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 myocardium 2. < End systolic volume of 130ml 3. Normal LV geometry Improvement continues 6 -12 months after surgery Arend F.L. Schinkel et al. JNM 2007 De Bonis et alSurgery insight Nat Clin Pract Cardiovasc Med 2006
Coronary Artery Revascularisation Benefits : improvement in symptoms: Symptom free 1 year 5 year Angina 98% 81% Heart failure 78% 47% 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 Benefits : improvement in survival: No RCT was available untill recently DUKEs database has compared CABG vs MEDICAL over 25 yearsSURVIVAL OF PATIENTS(P<0.0001)Years CABG MEDICAL1 83% 74%5 61% 37%10 42% 13% OConnor CM et al: A 25-year experience from the Duke Cardiovascular Disease Databank. Am J Cardiol 90:101, 2002
Coronary Artery Revascularisation Benefits : Improvement in survival: RCT – STICH ( Surgical Treatment of Ischemic Heart Failure). Eric J. Velazquez et al Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction N Engl J Med 2011
Coronary Artery Revascularisation Benefits : Improvement in survival: RCT – STICH ( Surgical Treatment of Ischemic Heart Failure).
Coronary Artery Revascularisation Benefits : Improvement in survival: RCT – STICH ( Surgical Treatment of IsChemic Heart Failure). 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 Eric J. Velazquez et al Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction N Engl J Med 2011
Coronary Artery Revascularisation Risks : Perioperative risk in patients with severe LVD range from 2 to 10%. Risk depends up on 1. Availability of targets 2. Viability 3. RV dysfunction 4. NYHA class 5. Increased LVEDP 6. Advanced age 7. Associated PAD/STROKE 8. COPD Pocar et al.CABG for ischemic cardiomyopathy ATS 2007 Hillis et al.outcome of patients in low EF after CABG Circulation 2006
Coronary Artery Revascularisation Guideline : (ACC/AHA) CABG in pts with poor LV function CLASS 1 : LMCA or its equivalents CLASS 2a : viable non contracting muscle CLASS 3 : with out evidence of ischemia and viability Hunt SA, et al: ACC/AHA 2009 : Circulation 2009 Rx for heart failure Eagle KA, et al: ACC/AHA 1999: Circulation 1999 Rx by CABG
Valvular Surgery1. Valvular heart disease that lead to LV dysfunction2. Valvular dysfunction secondary to primary cardiomyopathy
Valvular SurgeryValvular dysfunction– Mitral Valve Surgery. Mitral valve : MR is commonly observed in pts with poor prognosis and independent risk factor for poor outcome Ischemic / non ischemic MR Benefits / risks Current guidelines
Valvular SurgeryValvular dysfunction– Mitral Valve Surgery .
Valvular SurgeryValvular dysfunction– Mitral Valve SurgeryNon ischemic MR : Conventional teaching is surgical correction of MR is associated with prohibitive operative mortality Studies 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 SurgeryValvular dysfunction– Mitral Valve Surgery – Benefits . ACORN TRIAL : Non randominized ,30 centres , 193 pts , on medical therapy was done to evaluate safety and efficacy of MVR + CorCop cardiac support device. Change was also noted in MR , NYHA class . Acker MA, et al: Mitral valve surgery in heart failure: JTCS 2006
Valvular SurgeryValvular dysfunction– Mitral Valve Surgery – Risks/Disadvantages . 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). No current evidence of survival benefit after MR elimination
Valvular SurgeryValvular dysfunction– Mitral Valve Surgery – Guidelines. 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 therapy ACC/AHA 2006 and ESC 2007 suggest that mitral annuloplasty with an undersized rigid annuloplasty is beneficial.
Valvular SurgeryValvular dysfunction– Aortic Valve Surgery – Aortic Stenosis.
Valvular SurgeryValvular dysfunction– Aortic Valve Surgery – Aortic Stenosis. 82% 78% 41% 15% Pereira JJ, et al: Survival after AVR for severe AS with low transvalvular gradients and severe LVD. JACC 2002
Valvular SurgeryValvular dysfunction– Aortic Valve Surgery – Aortic Regurgitation. 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 Bhudia SK et al. improved outcomes after AVR in AR with LVD JACC 2007
Valvular SurgeryValvular dysfunction– Aortic Valve Surgery – Guidelines .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).
LV ReconstructionDOR procedure BATISTA procedure Overlapping-type left ventriculoplasty Yoshiro Matsui,et al. Left Ventricular Reconstruction for Severely Dilated Heart Ann Thorac Cardiovasc Surg Vol. 14, No. 2 (2008)
LV Reconstruction The goal of the operationis to reduce end systolicvolumes by at least 30%while ensuing that theventricle in not too smallRESTORE ( Reconstruction Endovascular Surgery Returning Torsion Original Radius Elliptical Shape To LV) STICH ( Surgical Treatment of Ischemic Heart Failure)
LV Reconstruction 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. Variable Preoperative Postoperative LV ESVI 80% 56% LVEF 29% 39% NYHA 67%(III) 87%(I – II) Over all mortality was 5.3% with 1,3,5 year survival rates of 92%,90% and 80%.
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 ReconstructionSTICH ( Surgical Treatment ofIschemic Heart Failure) P=0.84 P=0.70 Robert H. Jones et al. CABG with or without SVR NEJM 2009
LV Reconstruction STICH ( Surgical Treatment of Ischemic Heart Failure) 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. STICH trial didn’t prove or disprove the original hypothesis
LV Reconstruction Current guidelines : Class III Partial left ventriculectomy is not recommended in patients with nonischemic cardiomyopathy and refractory end-stage HF. (Level of Evidence: C)
Cardiac Support Devices Cardiomyopastly Limits ventricular dilationReduces LV stress ,with out causing constriction Prevents LV remodelling Starling RC, Surgical treatment of chronic congestive heart failure. In: Mann D, ed. Heart Failure: A Companion to Braunwalds Heart Disease, Philadelphia: WB Saunders; 2003
Cardiac Support Devices Cor Cap device (ACORN TRIAL) Ann Thorac Surg 2007The 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.
Cardiac Support Devices Current Guidelines:As of now current guidelines doesn’t suggest cardiac support device US FDA doesn’t approve cardiac support device as of now
Ventricular Assist Device Indications Types of devices Device selection Evidence Current guidelines
Ventricular Assist DeviceIndications for VAD Support Patient 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 failure LVEF < 25% VO2 < 14 cc/kg/min NYHA 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 Rose EA,et al. Long-term mechanical left ventricular assistance for end-stage heart failure. NEJM2001
Ventricular Assist DeviceTypes Of Devices: 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: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.
Ventricular Assist Device 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 pumps The 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 DeviceTypes 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: 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 DeviceSurvival 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)
Cardiac TransplantationRejection / immunosupressionInfection 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
Cardiac TransplantationOutcomes: 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 workTime Major cause of death (%death)< 30 days Non specific graft failure(41%)1year Non CMV infection1-5 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
Cardiac Transplantation Current guidelines: ACC/AHA CLASS I Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF. (Level of Evidence: B)
Lift is falling then…….????? We never know when and where accidents will happen to us OR people around us. Read on and hope this piece of information may help any of us when things do happen to yourself, our friends and our loved ones. One day, while in a lift, it suddenly broke down and it was falling from level 13 at a fast speed. Fortunately, I remembered watching a TV program that taught you must quickly press all the buttons for all the levels. Finally, the lift stopped at the 5th level. When you are facing life and death situations, whatever decisions or actions you make decides your survival. If you are caught in a lift breakdown, first thought in mind may be waiting to die... But after reading below, things will definitely be different the next time you are caught in a falling lift. First - Quickly press all the different levels of buttons in the lift. When the emergency electricity supply is being activated, it will stop the lift from falling further. Second - Hold on tight to the handle (if there is any).. It is to support your position and prevent you from falling or getting hurt when you lost your balance. Third - Lean your back and head against the wall forming a straight line. Leaning against the wall is to use it as a support for your back/spine as protection. Fourth - Bend your knees. Ligament is a flexible, connective tissue. Thus, the impact of fractured bones will be minimised during fall. For everyone, kindly do share this piece of information with your near and dear ones !!