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Non-transplant Surgical Management of Heart Failure after Myocardial Infarction

Non-transplant Surgical Management of Heart Failure after Myocardial Infarction. Intern 吳婉禎 2007/03/19. Outline. Introduction Concepts of Heart Failure (HF) after Myocardial Infarction (MI) Surgical Management of HF. CAD, MI  2/3 of CHF

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Non-transplant Surgical Management of Heart Failure after Myocardial Infarction

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  1. Non-transplant Surgical Management of Heart Failure after Myocardial Infarction Intern 吳婉禎 2007/03/19

  2. Outline • Introduction • Concepts of Heart Failure (HF) after Myocardial Infarction (MI) • Surgical Management of HF

  3. CAD, MI  2/3 of CHF • Immediate survival after MI: timeliness of appropriate reperfusion • Long-term prognosis: subsequent changes in LV morphology, shape and function • Post-infarction LV remodeling: ventricular dilatation and abnormal shape  systolic and diastolic dysfunction Surgical ventricular restoration: reshaping the adversely remodeled left ventricle, Coronary Artery Disease 15(2) 2004 91-98

  4. Outline • Introduction • Concepts of Heart Failure (HF) after Myocardial Infarction (MI) • Surgical Management of HF

  5. Heart Failure after Myocardial Infarction • Evolution: a sequence of Vessel – Muscle – Form • “Culprit vessel”: causes myocardial infarction • “LV culprit muscle”: a regional non contractile scar • Stretching of compensating remote muscle to change ventricular configuration  “Culprit form” • “Triple V” disease: Vessel, Valve and Ventricle

  6. Laplace’s Law • Stress/tension = (pressure x radius) ÷ (2 x wall thickness) • Vicious cycle Heart Failure Following Anterior Myocardial Infarction: An Indication for Ventricular Restoration, a Surgical Method to Reverse Post-Infarction Remodeling, Heart Failure Reviews, 9, 241-254 2004

  7. Concepts of HF after MI • Ventricular volume vs. ejection fraction (EF) • Ventricular wall and asynergy: the culprit muscle • Time related ventricular volume changes • Diagnostic options: • LV ellipse to sphere: “culprit form” • Structural consideration

  8. White: ESVI rather than E.F. as the prognosis barometer • LV volume: a sensitive prognostic parameter for both late and early events after a MI • Left ventriculograms: Ventricular structure and Surgical history, Heart Failure Reviews, 9, 255-268 2004

  9. Concepts of HF after MI • Ventricular volume vs. ejection fraction (EF) • Ventricular wall and asynergy: the culprit muscle • Time related ventricular volume changes • Diagnostic options: • LV ellipse to sphere: “culprit form” • Structural consideration

  10. The infarction impact on LV wall: • Prior to early reperfusion: transmural infarction  classic thinned, dyskinetic (paradoxical wall motion) LV aneurysm • With early reperfusion: epi- and mid-myocardium spared with endocardial necrosis  segmental akinesis (lack of contractility) Overview: Ventricular restoration – a surgical approach to reverse ventricular remodeling, Heart Failure Reviews, 9, 233-239 2004

  11. Endocardium and mid-myocardium damage >50% of the LV wall  incapable of functional recovery • Progressive heart dilatation follows asynergy of >50% (30%) LV circumfernce after anterior MI Overview: Ventricular restoration – a surgical approach to reverse ventricular remodeling, Heart Failure Reviews, 9, 233-239 2004

  12. Concepts of HF after MI • Ventricular volume vs. ejection fraction (EF) • Ventricular wall and asynergy: the culprit muscle • Time related ventricular volume changes • Diagnostic options: • LV ellipse to sphere: “culprit form” • Structural consideration

  13. GUSTO (1997): ESVI >40 ml/m2 a high incidence of CHF & poor long-term survival • HF developed by progressive decrease of compensatory contraction of remote muscle • Longitudinal post MI studies of ESVI are needed to follow contractile ventricular size and shape to determine the time course of dilation Ventricular structure and Surgical history, Heart Failure Reviews, 9, 255-268 2004

  14. Concepts of HF after MI • Ventricular volume vs. ejection fraction (EF) • Ventricular wall and asynergy: the culprit muscle • Time related ventricular volume changes • Diagnostic options: • Asynergic area: left ventricle (LV) culprit muscle • Remote muscle • End systolic volume index (ESVI) • LV ellipse to sphere: “culprit form” • Structural consideration

  15. Asynergic area: LV culprit muscle  Establish scar extent, due to non-functional area: • stops working immediately after coronary occlusion • reperfusion delayed >2 hours  remain non- function • the trigger for compensatory function of remote m.  progressive dilation (> 50% of LV circumference) • Remote muscles • Patient’s viability: capacity of remote muscle to develop compensatory contraction • Areas to be evaluated: the septum and lateral LV wall • ESVI • LV volume: a valuable surrogate for prognosis

  16. Concepts of HF after MI • Ventricular volume vs. ejection fraction (EF) • Ventricular wall and asynergy: the culprit muscle • Time related ventricular volume changes • Diagnostic options • LV ellipse to sphere: “Culprit form” • Structural consideration

  17. Normal heart vs. dilated heart • A spherical form result from: • Ischemic disease with loss of the apex from infarction • AV or MV insufficiency • Myocyte disease: muscle replaced by collagen • Restoration treatment of HF: surgical changing of the sphere like basketball heart into an elliptical shape Overview: Ventricular restoration – a surgical approach to reverse ventricular remodeling, Heart Failure Reviews, 9, 233-239 2004

  18. Concepts of HF after MI • Ventricular volume vs. ejection fraction (EF) • Ventricular wall and asynergy: the culprit muscle • Time related ventricular volume changes • Diagnostic options: • LV ellipse to sphere: “culprit form” • Structural consideration

  19. Francisco Torrent-Guasp: a rope like model – basal and apical loops Spatial orientation of the ventricular muscle band: Physiologic contribution and surgical implications, The Journal of Thoracic and Cardiovascular Surgery 122(2) 2001 389-392

  20. Configuration of muscle fibers at the apex: figure of 8 • Produce 60% E.F. with only 15% muscle fiber shortening • Transverse fiber direction: E.F.= 30%  increases to 60% with oblique direction Spatial orientation of the ventricular muscle band: Physiologic contribution and surgical implications, The Journal of Thoracic and Cardiovascular Surgery 122(2) 2001 389-392

  21. A failing heart: basal loop is intact but stretched, apical loop fibers become less oblique • Ischemic: precise infarct location • Non-ischemic: more global process, architecture has variable site location • Localizing major segments of intrinsic disease is essential Ventricular structure and Surgical history, Heart Failure Reviews, 9, 255-268 2004

  22. Outline • Introduction • Concepts of Heart Failure (HF) after Myocardial Infarction (MI) • Surgical Management of HF • Surgical ventricular restoration (SVR) • Partial ventriculectomy • Other methods of ventricular remodeling

  23. Principal Concept • Based upon LaPlace's law • Reduces the size of the ventricle • Restores the elliptical shape of the heart Return the left ventricular volume/mass ratio toward normal • Significantly improves the pumping action of the heart  Improves clinical status • Usually done with CABG, often done with valve repair

  24. Cooley, 1959 • The first surgical treatment • Large dyskinetic, LV aneurysm on CPB • Linear closure Ventricular structure and Surgical history, Heart Failure Reviews, 9, 255-268 2004

  25. Linear Repair • Not deal with septal aneurysm • Retension of this damaged area  recurrent HF • many years later • Leaving too small LV volume Cardiac Surgery in the Adult, L. Henry Edmaund Jr, 1997

  26. Stoney, 1978 • Ventricular aneurysmectomy • Emphesis on anteroseptal repair by using a flap of scarred tissue

  27. Jatene, 1984 • Imbricated the scar and reformed the elliptical scar Ventricular structure and Surgical history, Heart Failure Reviews, 9, 255-268 2004

  28. Circular Patch Repair Cardiac Surgery in the Adult, L. Henry Edmaund Jr, 1997

  29. Dor Procedure, 1984 • Eexclusion of the non-contracting myocardial scar • Endoventricular circular patch plasty (ECVPP) • Key features: • Inclusion of both akinetic and dyskinetic portion • Leave no external prosthetic material to produce heavy pericardial adhesion Cardiac Surgery in the Adult, L. Henry Edmaund Jr, 1997

  30. Dor Procedure • Key features: • Relieve ischemia by complete coronary revascularization: grafting the LAD  providing upper septal perfusion • Ventricular sizing: 60 mL/m2 (EDV<150 mL/m2) and 70 mL/m2 (EDV>150 mL/m2) Surgical left ventricular remodeling in heart failure, The European Journal of Heart Failure 7 (2005) 704-709

  31. Key features: • Diminish ventricular volume  diminish wall stress, reduce myocardial oxygen consumption • Minimize mass of abnormal myocardium  improve wall compliance, reduce filling pressure, enhance diastolic coronary flow • Reduction of wall stress  enhance contractile performance by incresing extent and velocity of systolic fiber shortening Surgical ventricular restoration: reshaping the adversely remodeled left ventricle, Coronary Artery Disease 15(2) 2004 91-98

  32. Key features: • Use the patch to redirect muscle fiber tension toward the normal helical arrangement, reestabilish ventricular wall continuity • Endoventricular patch plasty has today become the method of choice for most surgeons treating LV aneurysms or dyskinetic LV tissues! Surgical ventricular restoration: reshaping the adversely remodeled left ventricle, Coronary Artery Disease 15(2) 2004 91-98

  33. SAVER • Surgical anterior ventricular endocardial restoration • Utilize Dor’s principle with some technical modification SAVER in the dilated remodeled ventricle after anterior myocardial infarction, Journal of the American College of Cardiology 37(5) 2001 1199-1209

  34. Dor’s patch insertion: in the cardioplegia arrested heart • Modification: using cardioplegia arrest during CABG/MV repair or replacement followed by open-beating technique during patch placement SAVER in the dilated remodeled ventricle after anterior myocardial infarction, Journal of the American College of Cardiology 37(5) 2001 1199-1209

  35. Fontan, 1989 • Placed a circumferential suture around the border of ischemic and normal tissue to create an oval neck for patch placement after securing this suture • Patch: oval with a long diameter of 2 – 2.5 cm in situ  made 2.5 – 3 cm to compensate space taken up by suture line

  36. Cooley, 1992 • Excluding septal aneurysm wall by placing an endoventricular patch placed between the scarred and viable areas

  37. Outline • Introduction • Concepts of Heart Failure (HF) after Myocardial Infarction (MI) • Surgical Management of HF • Surgical ventricular restoration (SVR) • Partial left ventriculectomy • Other methods of ventricular remodeling

  38. Batista Procedure, 1994 • Partial left ventriculectomy (PLV) of viable tissues • Removed a wedge of LV muscles from the apex to the mitral annulus, between papillary muscles • MV was either preserved, repaired or replaced • Used to treat end-stage non-ischemic dilated cardiomyopathy • Favorable immediate and short-term (2–5 days) effects: reduced LV volume, increased E.F., and reduced wall tension • Improves LV and NYHA functional class in selected cases

  39. Limitation of Batista Procedure • Remove LV lateral wall irrespective of regional dysfunction used less for ischemic etiologies • Reduce systolic wall stress and improve E.F. • A deleterious effect on diastolic compliance: reduce recruitable stroke work (Starling law), magnitude of shape change or pumping capacity • SVR: resection of non-functional myocardium  resection of akinetic portion with normal thickness in dilated, poorly functioning heart

  40. Outcome of Batista Procedure • Long-term effectiveness for primarily IDCM: despite impressive improvement in acute LVEF (16–31%), disappointingly low event-free survival rates at 1 year (49%) and 3 years (26%) • Cleveland clinic: early and late failures preclude the widespread use of PLV • European Society of Cardiology: NOT recommend use of the Batista operation for HF or as an alternative to transplantation • ACC/AHA: class III procedure

  41. Outline • Introduction • Concepts of Heart Failure (HF) after Myocardial Infarction (MI) • Surgical Management of HF • Surgical ventricular restoration (SVR) • Partial ventriculectomy • Other methods of ventricular remodeling

  42. Acron CorCap Cardiac Support Device • A mesh-like device applied around the heart after opening the pericardium through midline sternotomy • A passive ventricular constraint will improve LV function and prevent further remodeling after MI Surgical left ventricular remodeling in heart failure, The European Journal of Heart Failure 7 (2005) 704-709

  43. Myosplint, 2002 • Reshape the spherical LV into ‘‘two elliptical’’ LV Surgical left ventricular remodeling in heart failure, The European Journal of Heart Failure 7 (2005) 704-709

  44. RESTORE Group • CABG: 95%, MV repair: 22%, MV replacement 1% • LVESVI: 109ml/m2 69ml/m2 • E.F.: 29.6%  39.5% • NYHA class: 67% III or IV  85% I or II • 30-day mortality: 5.3% • 18-month freedom from re-admission for CHF: 85% • Overall 5-year survival: almost 70%

  45. Risk Factors for Death • NYHA functional class IV • Age ≧75 years • EF ≦30% • LVESVI ≧ 80ml/m2(RESTORE group) • Pulmonary HTN (systolic PAP≧ 60 mmHg) • Greater number of previous MI • Right ventricular dysfunction • Urgent intervention

  46. Outcome • Di Donato: more strongly linked to the extent of asynergy than to the type of asynergy (akinetic compared with dyskinetic) • Most authors believe that surgical restoration of dilated left ventricles in terminal HF improves symptoms and life expectancy in properly selected patients • It is not yet proven that the surgical approach is better than medical therapy alone

  47. Take Home Massage • CHF: cardiac architecture departs from the normal and efficient elliptical form, by changing dimensions toward a less efficient spherical configuration or “the culprit form” • Surgical ventricular restoration: rebuilds the spherical structure toward more normal geometric configuration • Completes the “triple V” approach: SVR adds the ventricleto the prior vessel(CABG)and valve(MV repair / replacement)components that a surgeon traditionally addresses

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