management of DCM

1. Surgery for DCM and RCM
Dr Amjad Shaikh

2. Introduction
 Main treatment is for heart failure which is
the end result of DCM and RCM.
 Most of the surgeries still are under
development.
 Best treatment is heart transplant.

3. Surgery for DCM
 Partial left ventriculectomy( Batista)
 Ventricular restoration
 Ventricular shape change and constraint
devices
 Direct cardiac or aortic compression devices
 Dynamic cardiomyoplasty
 Biventricular pacing
 Mechanical circulatory support

4. Batista operation
 Batista procedure, was developed and introduced
by the Brazilian cardiac surgeon Batista.
 Batista hypothesized that an enlarged, dilated
ventricle would be a more effective pump if the size
could be reduced, hence restoring the normal
volume/mass/diameter relationship of the left
ventricle.
 The law of LaPlace states that wall stress is directly
proportional to ventricular pressure and radius and
inversely proportional to wall thickness.

5.  removing a triangular wedge of the lateral wall of the left
ventricle, which typically weighs more than 100 g . The
incision begins at the apex of the left ventricle and
extends to the atrioventricular groove.
 Typically a posterolateral branch of the left coronary
artery is removed with the excised specimen. Because of
the change in geometry and juxtaposition of the papillary
muscles, the mitral valve is repaired to ensure
competency.
 Batista performs a mitral valve repair (Alfieri technique),
in which the anterior and posterior leaflets are sutured
resulting in a double-orifice mitral valve, which yields the
characteristic figure-of-eight appearance when the mitral
valve is viewed in the short-axis echocardiographic view

6. Batista surgery

7. 2D Echo: figure of eight

8.  Advantages: it improves systolic function and
hence cardiac output..
 Limitations:
It removes functioning though weakened
myocardium. It may actually decrease net
ventricular pumping capacity by affecting
diastolic compliance.

9. Ventricular restoration
 Anatomical basis:
- heart is dual spiral helix( torrent – Gausp)
-configuration of muscle fibers at apex is figure
of eight which provides mechanism for
ventricular ejection and suction of filling.
Aim of surgery:
convert spherical heart to normal elliptical
heart

10. Ventricular shape change and
constraint devices
 These devices change left ventricular shape
or to restrain ventricular dilatation of heart.
 McCarthy and schenk used myosplints:
three of devices are placed perpandicular to
long axis of left ventricle.
Chaudhary used prosthetic jacket of knitted
polyster mesh: it prevents progressive left
ventricular remodelling and abolished
functional mitral valve regurgitation.

11. Direct cardiac or aortic
compression devices
 It helps failing heart by direct compression of heart and aorta.
 It avoids interaction between blood and foreign surface of assist
device.
 Ease of application and ease of removal.
A: The cardio support system:
it surrounds both ventricles to the AV groove
- -200 mm Hg pressure for vaccume seal.
- compression bladder inflated and deflated in synchrony with
cardiac contraction.
- short term use for cardiogenic shock.

13.  B: The heart booster:
- multiple small parallel compression tubes
covering both ventricular chembers.
- hydraulic drive system fills and empties the
tubes
- still under development stage

16.  C: Kantrovitz CARDIOVAD( LVAD):
Principle: diastolic augmentation like IABP.
- the pump is warn externally and provides the
stroke volume of up to 60 ml via the tube
through the skin.

18. Dynamic Cardiomyoplasty
 Basic: use of the skeletal muscle wrapped
around heart which is stimulated electrically
to augment or restore contractility of
ventricles.
 Kantrovitz and McKinon used first in 1959.
 Latissimus dorsi muscle used.
 Electrodes are implanted in muscle and
stimuled in synchronization with heart
 Late deaths are seen due to ventricular
arrhythmias and fibrillation.

20. Mechanical circulatory support
 It is a means of imparting energy for forward flow of
blood in the body by man made device.
 It can be
A: - temporary
- interim
- permanent
B: - internal (implantable)
- external( partially implantable, paracrporeal)

21. Implantable or partialy
implantable
 A: Ventricular Assist Device:
- VADs are connected to the failing heart in
parallel.
- it pumps all or part of stroke volume.
- It generally bypass the failing heart.
- It takes blood from atria in to the pump and
return to great arteries beyond the ventricle.
- It provides pulsatile blood flow

22. Paracorporeal VADS
 Abiomed VAD

23. Thoratec VAD

24.  It is particularly useful in smaller adults or
older children.
 Pumping ventricle is mounted on the
abdomen and canula from ventricle are
brought out of mediastinum as drainage
tube.
 Rate is determined automatically.
 The pump is flow limited to about 5l/m.

25. Implantable VADS
 Thoratec heartmate VAD II used as bridge to
heart transplant.
 It improves the chance for survival until the
suitable donor can be located.
 Pump is driven pneumatically or electrically.
 Many newer modifications are available now.

27. Total artificial heart
 Both ventricles are replaced by biventricular
pneumatic pulsatile blood pump maintaining
natural atria as inflow chambers.

28. cardiowest C-70

30. Recent advances
 Now continuous flow and centrifugal pumps
are available.
 these are smaller pumps
 Energy requirement is low
 Pumps do not require compliance chamber.
 Disadvantages: needs anticoagulants
thrombus formation
hemolysis.
( Nimbus heartmate II VAD)

31. Last resort….
 Heart transplant…

32.  Thank you….