Approcci Chirurgici nello Scompenso Cardiaco Avanzato
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Presentazione sul trattamento chirurgico dello scompenso avanzato - Operare il Cuore nel 2016
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Approcci Chirurgici nello Scompenso Cardiaco Avanzato
- 1. Approcci Chirurgici nello Scompenso Cardiaco Avanzato Giacomo Bianchi, MD, PhD! Ospedale del Cuore - Fondazione Toscana “G. Monasterio”
- 2. Ventricular Remodelling Techniques High Risk Conventional Surgery Ventricular Assist Devices Cardiac Transplantation Cardiac Surgeons’ Toolbox for Advanced Heart Failure CCH
- 3. CABG in Advanced Heart Failure George TJ et al. Prog Cardiovasc Dis 2011
- 4. Outcomes of CABG in Advanced Heart Failure Topkara et al Circulation 2005
- 5. Outcomes of CABG in Advanced Heart Failure Allman et al JACC 2002 Viability and Outcome
- 6. Mitral valve Surgery - Repair / Replacement Diodato et al. Ann Thorac Surg 2004 Mihaljevich et al. JACC 2007
- 9. Tools for Mitral Valve Surgery Mitral Repair Papillary Muscle Relocation Secondary Chordae Cut Restraint Devices Coapsys
- 11. SURGICAL VENTRICULAR RESTORATION George TJ et al. Prog Cardiovasc Dis 2011
- 12. 12
- 14. NumberofCentersReporting 0 75 150 225 300 Year of Transplant 1980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 Europe North America Other Current Heart Transplantation Data 2015
- 15. Current Heart Transplantation Data 2015 REGISTRY DATABASE: Average Annual Number of Transplants NumberofTransplants 0 875 1750 2625 3500 Europe North America Other ! Ad ! Pediatric ! Pediatric ! Pediatric! Adult ! Adult ! Heart-lungHeart Lung 2004-6/20141980-2003 ! Ad ! Pediatric ! Pediatric ! Pediatric! Adult ! Adult ! Heart-lungHeart Lung
- 16. Adult and Pediatric Heart Transplants Recipient Age Distribution By Era %oftransplants 0 17,5 35 52,5 70 Recipient Age 0-9 10-17 18-39 40-59 60-69 70+ 1982-1998 (N=57,137) 1999-2008 (N=39,879) 2009-6/2014 (N=22,781) !p < 0.0001 JHLT. 2014 Oct; 33(10): 996-1008 2015 JHLT. 2015 Oct; 34(10): 1244-1254
- 17. Adult and Pediatric Heart Transplants Recipient Age Distribution by Location (Transplants: January 2009 – June 2014) %ofrecipients 0% 25% 50% 75% 100% Europe North America Other 0-9 10-17 18-39 40-59 60-69 70+ Recipient age (years): mean/median Europe = 47/52 North America = 45/53 Other = 44/48 JHLT. 2014 Oct; 33(10): 996-1008 2015 JHLT. 2015 Oct; 34(10): 1244-1254
- 18. Adult and Pediatric Heart Transplants Donor Age Distribution by Location (Transplants: January 2009 – June 2014) %ofdonors 0% 25% 50% 75% 100% Europe North America Other 0-9 10-17 18-39 40-59 60-69 70+ Donor age (years): mean/median Europe = 40/43 North America = 28/27 Other = 32/30 JHLT. 2014 Oct; 33(10): 996-1008 2015 JHLT. 2015 Oct; 34(10): 1244-1254
- 19. Adult and Pediatric Heart Transplants Kaplan-Meier Survival (Transplants: January 1982 – June 2013) Survival(%) 0 25 50 75 100 Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 !Median survival = 11 years ! Median survival conditional on surviving 1st year = 13 years N = 112,521 N at risk at 30 years = 16 JHLT. 2014 Oct; 33(10): 996-1008 2015 JHLT. 2015 Oct; 34(10): 1244-1254
- 20. Major Drawbacks of HTX !Acute Rejection !Chronic Rejection !Infections !Malignancies !Prevalence of Advanced HF is 15700 - 156000 patients !HTX rate as little as 3500/year !20% pts die during the waiting list HF Epidemics After HTX
- 21. MECHANICAL CIRCULATORY SUPPORT WELCOME TO THE MACHINE LANDMARKS IN MECHANICAL ASSISTANCE DEVICES 1953 20101963 1968-9 1972 1985-6 1991 2000-1 2006-7 2001 REMATCH over 2006 AbioCor TAH INTERMACS 2008-10 HM II approval 1994-8 HM XVE REMATCHTAH as DT 1982
- 26. MECHANICAL CIRCULATORY SUPPORT WELCOME TO THE MACHINE POTENTIAL POPULATION FOR LONG TERM USE OF MCS NYHA functional class Specific Activity Scale Classification INTERMACS Time Course ACCF/AHA Stage VAD approval NYHA III a Marked limitations; comfortable at rest. Symptoms in «less than ordinary activities» Level 7 NYHA class III Stage C No current approval NYHA IIIb IIIa + symptoms at rest in past 6 months Level 6 NYHA class III, but experienced NYHA class symptoms in last 6 months Stage C No current approval NYHA IV Inabiltity to perform any physical activity without discomfort; symptoms at rest Levels 1-5 Stage C-D Currently approval
- 27. MECHANICAL CIRCULATORY SUPPORT WELCOME TO THE MACHINE POTENTIAL POPULATION FOR LONG TERM USE OF MCS CURRENT INDICATIONS FOR MCS MCS as DESTINATION THERAPY ! • Not transplant candidate • NYHA class IV Heart Failure on maximal medical therapy >60-90 days • Ejection Fraction <25% • Peak oxygen consumption <12 ml/kg/min MCS AS BRIDGE «THERAPY» ! • SAP <80 mmHg • MAP <65 mmHg • CI <2,0 L/min/m2 • PCWP >20 mmHg • SVR >2100 dynes-sec/cm
- 37. MECHANICAL CIRCULATORY SUPPORT WELCOME TO THE MACHINE HeartMate II Site of implantation: Preperitoneal pocket ! Inlet: left ventricle Outlet: ascending aorta ! Driveline: percutaneous ! Flow: up to 10 L/min Speed: 6000 – 15000 ! Actuator: magnet; electromotive force; titanium surface ! Management: anticoagulation ! BTT clinical trail: 489 pts; survival rate 73% at 18 months ! DT trial: HM II vs. HM XVD 1 year survival: 68% vs 55% 2 years survival: 58% vs 24%