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Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISE

Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010.

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Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISE

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  1. Tenth International Symposium HEART FAILURE & Co. CARDIOLOGY SCIENCE UPDATE FEMALE DOCTORS SPEAKING ON FEMALE DISEASES Milano 9 - 10 aprile 2010 Rimodellamento Ventricolare e Conversione del Rimodellamento: soni processi confrontabili nei due sessi?Marisa Di DonatoIRCCS San Donato HospitalUniversity of Florence

  2. Sex impact on remodelingAging cardiomyopathy Piro et al. JACC 2010;55:1057

  3. Aging cardiomyopathy The basis for the differential impact of aging on the heart is unknown A potential explanation may be related to the higher cardiac work load of male hearts throughout life Another explanation could be the higher rate of apoptosis in men

  4. Sex impact on remodelingResponse to Pressure Overload Piro et al. JACC 2010;55:1057

  5. Sex impact on remodelingResponse to Volume Overload Piro et al. JACC 2010;55:1057

  6. Sex impact on remodelingResponse to acute myocardial ischemia Piro et al. JACC 2010;55:1057

  7. Sex impact on remodelingHeart Failure

  8. Sex impact on remodeling and the role of estrogens The mechanism by which estrogens exert their cardio-protective effects are not completely understood Ovarian synthesis of estrogens is subject to dramatic changes during the course of life but intramyocardial synthesis is less influenced by such variations (Grohe 1998)

  9. Sex impact on remodeling and the role of estrogens Metabolic and vascular effects Endotelium-dependent flow-mediated dilatation and aortic compliance are greater in women Estrogens reduce cytopatic damage associated with myocardial injury (less apoptosis) Androgens adversely affect myocardial healing (Higher rate of rupture in men) and promote cardiac remodeling and dysfunction

  10. Diastolic Heart Failure • The reduced ventricular dilatation during remodeling in women compared with men helps explain why approximately half of women presenting with HF symptoms have preserved EF, vs one/third of men(Cleland JC, Eur Heart J 2003) • When affected by HF women are more likely than men to present with congestive symptoms • Both men and women with diastolic dysfunction and preserved EF show an increase in End diastolic pressure-volume ratio

  11. IRCCS Policlinico San Donato THE PROCESS OF POST_INFARCTION REMODELING Gender & Heart Failure ●Myocardial Changes Myocyte loss Necrosis Apoptosis ●Alterations in extracellular matrix ●Matrix degradation ●Replacement fibrosis ● Alteration in LV chamber geometry ● LV dilation (SIZE) ● Increased LV sphericity (SHAPE) ● LV wall thinning (SHAPE) ● Mitral valve incompetence (SIZE AND SHAPE)

  12. Sex Differeces after MI 0.02 0.001 0.05 496 pts (89 women) San Donato Hospital (unpublished)

  13. Pattern of LV Remodeling after Myocardial Infarction In Women % Concentric Eccentric Dilatation 496 pts (89 women) San Donato Hospital (unpublished)

  14. Pattern of LV Remodeling after Myocardial Infarction In Men % Concentric Eccentric Dilatation 496 pts (89 women) San Donato Hospital (unpublished)

  15. Sex impact on LV Remodeling after Myocardial Infarction EDVI(ml/m2) ESVI(ml/m2) 0.001 0.001 496 pts (89 women) San Donato Hospital (unpublished)

  16. Sex impact on LV Remodeling after Myocardial Infarction Relative wall Thickness P 0.04 496 pts (89 women) San Donato Hospital (unpublished)

  17. Sex impact on LV Remodeling after Myocardial Infarction LV Mass Index(g.m2) Left Atrium Size (mm) 0.006 0.003 496 pts (89 women) San Donato Hospital (unpublished)

  18. Sex impact on LV Shape after Myocardial Infarction Sphericity Index= Short to Long axis ratio S P H E R I C I T Y I N D E X 0.007 0.001 Women Men San Donato Hospital (unpublished) (Median Values)

  19. Sex impact on LV Apical Shape (Conicity Index) after MI Diastole 0.01 0.001 0.001 Conicity Index (CI)= Apical to Short axis ratio MI N MI N Systole 0.0001 0.001 0.001 San Donato Hospital (unpublished) MI N MI N

  20. Sex impact on Global and Regional LV shape after MI SI= 0.46 CI=1.12 SI= 0.55 CI=0.78 L S A Sphericity Index= S/L Conicity Index= A/S

  21. Is it possible to revert LV remodeling? Is there a difference in women compared to men in reverting the remodeling process ?

  22. Non pharmachologic approaches to revert/retard LV remodeling ● Cardiomyoplasty ● Volume reduction surgery (Batista operation) ● Mitral valve repair +/-CABG ●VAD implantation ● CRT ● LV reconstruction (Dor procedure) ● Mannequin guided surgical ventricular restoration (SVR- Menicanti) ● Prosthetic restraint devices ● Cells replacement

  23. San Donato Hospital, Milano Italy Surgical technique • Arrested heart • Use of intraventricular mannequin to re-size and re-shape • Complete coronary revascularization • Mitral repair through ventricular approach, if needed • Cryosurgery at the border of the lesion if VA present Menicanti 2002

  24. San Donato Hospital SeriesPts submitted to SVR (2001-2009) O496 Patients with previous MI: • 89 Women (age 68+/-10 yrs)** • 407 Men (age 64+/-9 yrs) ONYHA III-IV: • Men 166/384 (43%) • Women 50/83 (56%)** O CABG associated in 93% of women and 94% of men O Mitral repair in 25% of men and 27% of women O Operative mortality: Men 27/408 (7.6%) Women 9/89 (10%) NS

  25. ….SURGERY for LV remodeling Pre Pre Post Post

  26. Reverse remodeling at 12 months FUP induced by SVR + Women Men

  27. Reverse remodeling at 12 months FUP induced by SVR Apical Axis Long Axis Short Axis Apical Axis Long Axis Short Axis Women Men

  28. Changes in Sphericity Index following SVR 0.01 0.01 Diastole 0.01 Systole Pre-op Post-op Pre-op Post-op

  29. Sex impact following Surgical Ventricular Reconstruction for post-infarction LV remodeling

  30. LVR can revert the remodeling process both in men and women, by reducing Ventricular size and improving apical shape A more physiologic apex is the key to re-direct the blood flow towards the aorta and improving cardiac function Prognosis following LVR is not impacted by sex Conclusions

  31. Conclusions Regardless of age and menopause the remodeling process appears to be more favourable in women Women are more likely to present with “diastolic only” dysfunction and are at greater risk for low output syndrome acutely Lower awareness of heart disease in women is likely responsible for the worse outcome observed in some clinical series, and since this issue can be corrected,increased awareness of heart disease among women should still represent a number one priority

  32. THANKS

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