Surgery of dd bianchi presentation
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Diastolic Disease - Surgical Overview of treatment options
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Surgery of dd bianchi presentation
- 1. DIASTOLE DISEASED - 2016 Surgical treatment of Diastolic Disease: Mithology Giacomo Bianchi, MD, PhD! Ospedale del Cuore! Dept Adult Cardiac Surgery! Fondazione Toscana “G. Monasterio”
- 2. Surgical Treatment of Pathologies and the underlying Diseased Diastole Determinants of Diastolic Disease! • External constraint! • intrinsic myocardial muscle disease! • impaired/mismatched myocardial blood flow! • myocardial adaptation to abnormal hemodynamic burden Constrictive Pericarditis HOCM Ischemic Heart Disease Valvular Heart Disease
- 4. Galenus 160 AD Report (comparative anatomy) Lower 1669 Acute and Chronic Pericardial Thickening Bonetus 1679 Report Lancisi 1715 Autoptic finding: “Small heart encased in thickened pericardium; abdomen swelling; enlarged jugular vein” Vieussens 1716 Report Morgagni! Laennec 1760 “Pericardial adhesions are a rarely associated with symptoms” 1819 Cheevers! Greisinger! Wilks! Kussmaul 1872 “Chronic constrictive pericarditis could be clinically relevant” 1856 1870 1873 Pick 1896 Report HOCM - Mythology and Epos MYTHOLOGY
- 5. Weil! Delorne ! Wigle 1895! 1899! 1902 Suggested! “Pericardiectomy” Hallopeau 1921 First Pericardiectomy Rehn! Sauerbruck 1913 Partial pericardiectomy Schneider! Fisher 1929 Pericardiectomy Beck 1929-1931 Pericardiectomy - Experimental constrictive pericarditis Blalock! Burwell 1941 First series of 28 patients HOCM - Mythology and Epos EPOS
- 6. Diastolic Heart Failure - Constrictive Pericarditis Translational Approach
- 8. Tubercolous HIV! related Post- surgicalPost- surgical Contemporary Worldwide Distribution 2015 ESC guidelines for the diagnosis and management of pericardial diseases
- 9. Villavicencio et al. Op Tech CardioThor Vasc Surg 2008
- 10. Szabó G et al. Eur J Cardiothorac Surg. 2013 Pericardiectomy Outcome by Symptoms by Etiology
- 11. Busch et al Eur J Cardiothorac Surg 2015
- 12. Kang et al. J Thorac Cardiovasc Surg 2014
- 13. • Comparable post-op LAP ! • Abnormal Diastole: longer duration of symptoms before surgery Senni et al JACC 1999 Kim JS et al Int J Cardiol 2009 DE: doppler echocardiography
- 14. Veress G et al. Circ Cardiovasc Imaging. 2011
- 15. Motoki H et al. JASE 2013 Contractile Reservoir Conduit
- 16. Surgery - DD - Constrictive Pericarditis ❖ Pericardiectomy is effective in relieving constriction of the heart! ❖ Symptoms improvement occur in a significant proportion of patients! ❖ Prognosis is still linked to preoperative functional status and duration of the disease! ❖ Diastolic function analysis after treatment may unmask patients with underlying disease, extensive myocardial damage, untreated comorbilities.
- 18. Hallopeau!1869! Liouiville!1869! Schminke!1907 Pathology Description! (reports of findings compatible with HOCM) Davies 1952 Description of familiar HOCM and report of 3 cases of sudden death Brock 1957 diffuse subaortic stenosis! “Functional obstruction of the left ventricle” Brock 1957-1959 “Surgical report” ! (no surgical treatment provided) Teare 1958 first accurate categorisation of HOCM! (muscle fibers thickening and disarray) Fix 1964 Recognise the contribution of the AL of mitral valve: SAM Godwin! Oakley 1960-1972 Reduced LV compliance; “inflow” obstruction HOCM - Mythology and Epos MYTHOLOGY
- 19. Cleland 1960 First performed surgical incision - myotomy Kelly! Morrow! Wigle 1966! 1961-1964! 1962 Routinely performed ! “Myotomy” Kirklin 1961 Surgical excision of hypertrophied muscle - “Myectomy” Troubl 1962 Aortic approach Lillehei! Levy 1963 Treatment of anterior leaflet of mitral valve Dobella! Scott 1964 Left atrial approach Swan 1964 Ventriculotomy approach Julian 1965 “Fishmouth” ventriculotomy Morrow 1975-1978 Trans-aortic myectomy Cooley 1973-1976 Mitral valve replacement HOCM - Mythology and Epos EPOS
- 20. from Dearani J - Op Techn Thor Cardiovasc Surg 2004
- 21. 1975-1993 Cosgrove D et el. JTCVS 1995 SM SM + MVR Robbins RC et el. JTCVS 1996 1973-1995
- 22. 1983-2001 Ommen SR et el. JACC 2005 Sedehi D et el. J Cardiol 2015 1972-2006 1994-2005 Smedira NG et el. Ann Thorac Surg 2008
- 23. Effect of Septal Myectomy on Diastolic Function Small proportion of SM patients had decrease in DT, but not in E and E/A ratio Masuyama et al. JASE 1990 Non-surgical septal reduction therapy: decrease in pre-A pressure and tau velocity with increase of Ea and LVEDV Nagueh SF et al. Circulation 1999 Both myectomy and PTSMA reduce LVOT obstruction and significantly! improve NYHA functional class in patients with HOCM Qin JX et al. JACC 2001 […]diastolic function indexes obtained by echocardiography changed after septal reduction interventions in patients with obstructive HC. Sitges M et al. Am J Cardiol 2003 Valeti U et al. JACC 2007
- 24. Effect of Septal Myectomy on Diastolic Function Monteiro PF et al. Am J Cardiol 2007 Pre-Myectomy Post-myectomy p-value LVOT 106±44 17±13 <0.001 MR grade 3±1 2±1! <0.001 RSVP 40±8 31±6 <0.01 E/E’ 20.7±6.0 10.8±4.0 <0.01 LAVI 52.1±21.2 33.2±11.9 <0.001 LAVI! pre-myectomy: ! MR grade (r2=0.76); p=0.003! ! ! ! ! E/E’; p=0.03! ! post-myectomy:! LVOTG (r2=0.33); p=0.006!! ! Menon SC et al. JASE 2008 Yang H et al. JASE 2005
- 25. Effect of Septal Myectomy of Diastolic Function Tower-Rader A et al. Am J Cardiol 2014 Moravsky G et al. JASE 2013 *
- 26. Surgery of DD - Hypertrophic Obstructive Cardiomyopathy ❖ Surgical treatment in obstructive forms guarantees a “normal” lifespan! ❖ Septal myectomy is still the most reliable, reproducible and effective procedure for HOCM! ❖ Prognosis is still dictated by the form and thus the age of presentation! ❖ Septal myectomy advantage goes beyond the wall thickness and LVOTG reduction, involving also improvement of diastolic function! ❖ E/E’, LAVI and speckle tracking parameters are potential markers of myectomy effectiveness and also has the potential of prognostic values.
- 27. Diastole Diseased Aortic Stenosis Surgical Treatment! Mythology
- 28. Smith et al. Circulation 1978
- 29. Dweck et al JACC 2012
- 30. Normal Collagen Increased ! Collagen Cross-Hatching! +/-! Endocardial Fibrosis Increased collagen! Cross-Hatching! +/-! Endocardial Fibrosis Villari B et al. JACC 1992
- 31. Control Subjects Patients With Aortic Stenosis Pre- operative Early Post- operative Late Post- operative Muscle fiber diameter, μm 21±2 33 ±4 29±4 28±3 Interstitial fibrosis, % 7 ±2 16±5 28±8 13±2 Fibrous content, g/m 6±2 33±10 39±20 15±4 FC/EDVI, g/mL 0.07±0.02 0.28±0.09 2 0.46 ±0.23 0.14±0.04 Villari B et al. Circulation 1995
- 32. Lamb et al. JACC 2002
- 33. Ikonomidis I et al. Heart 2001
- 34. Asymptomatic Symptomatic Lund et al. Eur Heart J 1997 Biner et al. JACC Cardiovascular Imaging 2010 PROGNOSTIC VALUE OF E/E’
- 35. Brown J et al. Am J Cardiol 2009
- 36. Adjunctive pharmacological strategies Dahl JS et al. Am J Cardiol 2010
- 37. Dahl JS et al. Int J Cardiol 2013 Adjunctive pharmacological strategies
- 38. Diastole Diseased Aortic Regurgitation Surgical Treatment! Mythology
- 39. Villari B et al. Am J Cardiol 1992 Abnormal Diastole Indexes and Increased Myocardial Stiffness in Aortic Regurgitation
- 40. EFchange Deceleration Time (ms) E/A Cayli M Clin Cardiol 2009
- 41. Villari B et al. Circulation 2009
- 42. Zendaoui A et al.Circ Heart Fail 2011 Adjunctive pharmacological strategies
- 43. Sampat U et al. JACC 2009
- 44. Surgery of DD - Aortic Stenosis and Regurgitation ❖ Aortic valve disease is a disease of the valve and the myocardium! ❖ Myocardial remodeling, although with a different “primum movens”, eventually affects the diastole! ❖ Hypertension, vascular disease, diabetes mellitus, COPD, renal disease could coexist, over impose their features in terms of diastole remodelling, exacerbate ultimately leading to a vicious cycle! ❖ Relieve of the increased afterload is effective in modifying the natural history of the disease per se and also promoting a reverse remodelling! ❖ Adjunctive pharmacological strategies are necessary to obtain the maximum from the therapeutic intervention! ❖ In patients that fail to improve after surgery, underlying advanced diastolic disease could provide an explanation and also a further preoperative tool to stratify intervention timing.
- 45. Conclusions ❖ Diastolic disease is an underlying and often overlooked feature of many cardiac pathologies.! ❖ Surgical treatment often address the main feature of the disease! ❖ Diastolic disfunction could impact heavily on patients’ prognosis! ❖ A better understanding of the diseased diastole in surgical patients and its impact on early and late outcome could lead to a better timing of the intervention and improved prognosis
- 46. THANK YOU for your attention