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What Can the Surgeon Do to Avoid Heart Replacement?

Ninth International Symposium HEART FAILURE & Co. Rozzano ,April 17, 2009. What Can the Surgeon Do to Avoid Heart Replacement?. Paolo Ferrazzi Dipartimento Cardiovascolare Ospedali Riuniti Bergamo. Valvular Disease. Hypertension. Cardiomyopathies. DIABETES. Myocardial Infarction.

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What Can the Surgeon Do to Avoid Heart Replacement?

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  1. Ninth International Symposium HEART FAILURE & Co. Rozzano ,April 17, 2009 What Can the Surgeon Do to Avoid Heart Replacement? Paolo Ferrazzi Dipartimento Cardiovascolare Ospedali Riuniti Bergamo

  2. Valvular Disease Hypertension Cardiomyopathies DIABETES Myocardial Infarction Delayed Primary PTCA HEART FAILURE End Stage HF (10%) SURGERY

  3. Surgical Treatment of Heart Failure in Italy • HTx • 344/yrs • VAD 30/yrs • Conventional Surgery • n° ? ISCHEMIC VALVULAR HYPERTENSIVE • 25.000 End Stage IDIOPATIC • 250.000 Heart failure

  4. Heart Failure Surgical Options • Heart Transplant • VAD (recovery, continuous flow) • Mitral annuloplasty ICM worse results then DCM!!!

  5. Substitutive Surgery Transplantation: shortage of donors VAD: cost, management, complications Reconstructive Surgery SVR + CABG (STICH Results) No basic research Sugical Treatment of Heart Failure

  6. STICH Results Personal Opinions • Comparison CABG vs SVR + CABG instead of HTx vs SVR + CABG in a sub-class of patients • VO2max and right catheterization not available • In more experienced Centers: exclusion from randomization of patients with a strong indication to SVR • Regional differences in surgical results • SVR long tradition? • Inadeguate mean ESV reduction (-19%) in SVR patients

  7. SVR & diastolic function … presented for the first time in 2000! Post-op ECHO study Mathematical model Clinical follow-up Animal study SYSTOLIC FUNCTION DIASTOLIC FUNCTION Systolic improvement is paid by some diastolic dysfunction

  8. Passive Diastolic Function ….a black hole in echocardiography Systolic Function Early Diastole Late Diastole • Fractional shortening • Vcf • Stress-corrected Vcf • Ejection fraction • Tei index • Strain and strain rate • TDI S-wave • E/A ratio • DT msec • IVRT msec • PV S/D ratio • TDI-E/E’

  9. Clinical ResearchSVR ….. thinking to diastolic function: The “horseshoe repair” Potential Advantages Horseshoe repair •  Volume •  EqD •  Eccentricity index •  Stroke volume • Late diastolic function  Ferrazzi, et al JTCVS 2008

  10. SVR – “HORSESHOE REPAIR” • Apr 2005 - Dec 2008 • n pts34 Age (mean)59.07±8.9 Mitral repair 21 pts (61%) Follow-up (mean)16±10.3 mo Hosp. Mortality2 pts (5.8%) Fu mortality 2* *1 pneumonia after4 mo and 1 sudden death after2 mo Follow-up Preop P-value 3.0±0.2 1.3±0.5 0.0001 NYHA VTSV sn (ml) 0.0001 174.0±56.3 96.8±29.3 (-44%) Ø Equatoriale (mm) 64.2±5.5 50.3±7.7 0.0001 Ø Longitudinale (mm) 99.5±13.4 84.1±11.6 0.002 27.1±5.7 40.0±8.2 0.0001 FE (%)

  11. Experimental ResearchThe Endoventricular Elastic Devices • Restore the elasticity of the dilatated heart • Reduce left ventricle volume • Store wasted energy during the diastolic phase • Give the stored energy back during the sistolic phase Ferrazzi, et al J Cardiovasc Med 2006

  12. Ischemic Heart Failure COMPLEXPATHOPHYSIOLOGICAL MECHANISM OF FUNCTIONAL MITRAL INCOMPETENCE • VALVE • PAPILLARY MUSCLES • LEFT VENTRICLE

  13. Work in progress...

  14. Cardiac surgery Surgical Trial Personalized surgery Current Practice: One size fits all !

  15. Heart Failure: back to surgical research... ANATOMY & GEOMETRY GENOMICS & BIOLOGY HEARTFAILURE BIO ENGINEERING PHYSIOLOGY

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