Sur gical Ventricular Remodeling for Congestive Heart Failure

1. Sur gical Ventricular Remodeling for Congestive Heart Failure “When BB and ACEI are not Enough” May 18th 2006 Jeffrey Marogil Malek Massad

2. Heart FailureIntroduction • Major Health Concern in US • Affects 4.8 million people in U.S. • 400,000 new cases each year. • Anticipated increase in incidence & prevalence as population ages.

3. INTRODUCTION • Significant progress has been made in the medical management of patients with heart failure • However the surgical management of patients with end-stage heart failure has evolved in a less structured fashion

4. INTRODUCTION • Heart transplantation remains the ultimate treatment for heart failure

5. INTRODUCTION • Cardiac transplantation is currently the only established surgical approach (excluding AVR and CABG) for the treatment of refractory HF as listed in the 2005 ACC/AHA heart failure guidelines

6. INTRODUCTION • Cardiac transplantation is currently the only established surgical approach (excluding AVR and CABG) for the treatment of refractory HF as listed in the 2005 ACC/AHA heart failure guidelines • Small number of available donor hearts • Inapplicable in older pts or those with comorbid conditions

7. NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR AND LOCATION

8. Need for Heart Transplant# of Potential Recipients that can Benefit from OHT

9. HEART TRANSPLANTATION ACTUARIAL SURVIVAL(1982-2000) Half-life =9.1 years Conditional Half-life = 11.6 years N=52,195

10. ADULT HEART TRANSPLANTATION Actuarial Survival by Diagnosis (Transplants: 1/1982-6/2001)

11. Who Should Not Be Offereda Heart Transplant? • Irreversible PHTN or pulmonary parenchymal disease • Irreversible renal or hepatic dysfunction • Severe peripheral or cerebrovascular disease • IDDM with end-organ damage • Coexisting cancer • Non-compliance, addiction • Elderly patients (aprox > 70yo)

12. Surgical Ventricular Remodeling • Other Surgical Treatment Options are needed since transplants limited by • Available donors • Suitable recipients

13. Surgical Treatment of heart failure • Coronary revascularization in ischemic cardiomyopathy • Mitral valve repair in patients with dilated cardiomyopathy. • Left ventricular assist devices (LVADs) • Resynchronization therapy • Total Artificial Heart • Reconstructive cardiac surgery

14. 2005 ACC/AHA Guidelines • Alternate surgical and mechanical approaches for the treatment of end-stage HF are under development. Chronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for the Diagnosis and Management August 16, 2005

15. Surgical remodeling for heart Failure • Theory behind treatment • History of procedures • Ischemic • Batista • Left ventricular aneurysmectomy • Nonischemic • Cardiomyoplasty Current and Future LV Reconstructive procedures • Ischemic • Dor procedure • Non-ischemic Acorn & myosplint Conclusions

16. Theory • Systolic HF leads to an enlarged LV volume to maintain stroke volume • This leads to increase in wall stress due to Laplace's law stress = pressure x radius ÷ 2 x wall thickness • The ventricular geometry becomes less ellipsoid and more spherical leading to progression of left ventricular dysfunction and worsening heart failure.

17. Theory • Removing or excluding portions of the dysfunctional myocardium returns the left ventricular cavity to a smaller chamber with more normal geometry • This should improve cardiac work efficiency and theoretically should improve heart failure symptoms. • Ideally it would also translate into prolonged survival

18. Theory • In the 1990’s studies showed a relationship between LV size and Mortality

19. Theory • 382 patients with NYHA III and IV • LV size measured by EDV/BSA • LV size was a predictor of sudden cardiac death • LV’s > 4 cm/m2 had a 2 year survial of 49% compared to 75% if < 4 cm/m2 • Independent of disease and %EF Lee th et al Am J Cardiology 1993;72:672-676

20. Surgical remodeling for heart Failure • Theory behind treatment • History of procedures • Ischemic • Batista • Left ventricular aneurysmectomy • Nonischemic • Cardiomyoplathy Current and Future LV Reconstructive procedures • Ischemic • Dor procedure • Non-ischemic Acorn & myosplint Conclusions

21. Batista procedure • Batista procedure also called the partial left ventriculectomy (PLV) • Developed by Dr. Randas Batista (Brazil) in 1996

22. Partial Left Ventriculectomy(Batista Operation) Removal of a section of the left ventricular free wall, between both papillary muscles and extending from the apex to the mitral annulus Remaining free edges were re- -approximated and stitched together Mitral valve and subvalvular apparatus were either preserved, repaired, or replaced,

23. Partial Left Ventriculectomy(Batista Operation) UIC

24. Partial Left Ventriculectomy(Batista Operation) • Initial experience with the Batista procedure demonstrated an initial increase in LVEF, reduction in heart size, and improvement in clinical functional status • However, of 120 patients Batista reported a 22% operative mortality and 2 year survival of 55%.

25. Partial Left Ventriculectomy(Batista Operation) • Late fatal arrhythmias plagued this procedure, forcing the use of concomitant implantable defibrillators • Therefore the Batista procedure has fallen out of favor and is no longer considered to be an appropriate option

26. Surgical remodeling for heart Failure • Theory behind treatment • History of procedures • Ischemic • Batista • Left ventricular aneurysmectomy • Nonischemic • Cardiomyoplathy Current and Future LV Reconstructive procedures • Ischemic • Dor procedure • Non-ischemic Acorn & myosplint Conclusions

27. Left ventricular aneurysmectomy • The first successful surgical correction of an LV aneurysm occurred in 1957 by Dr. Bailey • Done without off cardiac bypass by placing a clamp on the base of an aneurysm and passing suture beneath allowing excision of the aneurysm.

28. Left ventricular aneurysmectomy • Dr. Denton Cooley performed a resection of an LV aneurysm one year later on bypass which remained the standard for nearly 30 years.

29. Left ventricular aneurysmectomy • A 2004 ACC/AHA task force concluded that it is reasonable (class IIa recommendation) to consider aneurysmectomy, accompanied by coronary artery bypass grafting (CABG), in patients with a left ventricular aneurysm in the setting of an acute MI who have intractable ventricular arrhythmias and/or heart failure unresponsive to medical and catheter-based therapy

30. Surgical remodeling for heart Failure • Theory behind treatment • History of procedures • Ischemic • Batista • Left ventricular aneurysmectomy • Nonischemic • Cardiomyoplathy Current and Future LV Reconstructive procedures • Ischemic • Dor procedure • Non-ischemic Acorn & myosplint Conclusions

31. Cardiomyoplasty • Cardiomyoplasty, also referred to as "dynamic cardiomyoplasty," • Surgical therapy for dilated cardiomyopathy in which the latissimus dorsi muscle is wrapped around the heart and paced during ventricular systole.

32. Cardiomyoplasty • Carpentier and Chachques peformed the first successful surgery on a humen in 1985

33. Cardiomyoplasty • Symptomatic improvement occured after cardiomyoplasty • Mechanism for improvement is unclear • Pacemaker synchronization was critical for obtaining optimal improvement.

34. Cardiomyoplasty • 600 patients undergoing this procedure found that, over time, the operative mortality decreased from 31 to 3 percent • Improvement in NYHA classification occurred in 80 to 85 percent of hospital survivors • However, long-term outcome data with cardiomyoplasty are limited.

35. Cardiomyoplasty • A large, randomized clinical trial of cardiomyoplasty was initiated for NYHA class III heart failure patients • Plagued by lagging randomization and marginal overall clinical improvement culminated in the premature termination of the study.

36. Cardiomyoplasty • “It appears that those who can survive the operation do not need it and those who need it, cannot survive it” • Leier, CV. Cardiomyoplasty: is it time to wrap it up?. J Am Coll Cardiol 1996; 28:1181.

37. 2005 ACC/AHA Guidelines • Although both cardiomyoplasty and left ventriculectomy (Batista procedure) at one time generated considerable excitement as potential surgical approaches to the treatment of refractory HF these procedures failed to result in clinical improvement and were associated with a high risk of death Chronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for the Diagnosis and Management August 16, 2005

38. 2005 ACC/AHA Guidelines • A variant of the aneurysmectomy procedure is now being developed for the management of patients with ischemic cardiomyopathy, but its role in the management of HF remains to be defined. Chronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for the Diagnosis and Management August 16, 2005

39. Surgical remodeling for heart Failure • Theory behind treatment • History of procedures • Ischemic • Batista • Left ventricular aneurysmectomy • Nonischemic • Cardiomyoplathy Current and Future LV Reconstructive procedures • Ischemic • Dor procedure • Non-ischemic Acorn & myosplint Conclusions

40. LV Reconstruction for Ischemic Cardiomyopathy • Dor procedure also called endoventricular circular patch plasty (EVCPP), is an approach to surgical reconstruction in the setting of postinfarction aneurysm formation first reported in 1985 • Advantage to aneurysmectomy is in an attempt to restore left ventricular geometry

41. Dor procedure for Ischemic Cardiomyopathy • May be considered in patients with symptomatic aneurysms as defined by heart failure, angina pectoris, systemic embolization, and/or malignant ventricular tachyarrhythmias.

42. Dor procedure for Ischemic Cardiomyopathy Purse string stitch around a nonviable scarred aneurysm to minimize the excluded area. The residual defect is sometimes covered by a patch made from Dacron, pericardium, or an autologous tissue flap

43. Dor procedure for Ischemic Cardiomyopathy The remaining aneurysmal scar is closed over the outside of the patch to give additional stability to the repair. The result is a more normal left ventricular chamber geometry and overall function

44. Dor procedure for Ischemic Cardiomyopathy The operation shortens the long axis, but leaves the short axis length unchanged, producing an increase in ventricular diastolic sphericity while the systolic shape becomes more elliptical

45. Dor procedure for Ischemic Cardiomyopathy • The first 661 patients • Overall operative mortality was 8 percent; (urgently 16.3 versus 6.2 percent when planned) • LVEF less than 20 percent (17 versus 1.4 percent for LVEF greater than 40 percent) Jpn J Thorac Cardiovasc Surg 1998 May;46(5):389-98

46. Dor procedure for Ischemic Cardiomyopathy • 495 patients available for follow-up, there was dramatic improvements • Overall LVEF improved from 33% versus 50% at one week postoperatively) maintained at one year. • The end-diastolic volume index decreased and symptomatic heart failure status, (212 pt) at one year, improved in 92 percent; • In addition, 91 percent of patients with spontaneous ventricular tachycardia were free of arrhythmia at one year.

47. LV Reconstruction for Ischemic Cardiomyopathy • At present there are four variations of LV reconstruction are used excluding the septum • Linear closure by Jatene • Modified liner closure by Mickleborough • Circular closure with a path by Dor • Circular closure without a patch by McCarthy

48. LV Reconstruction for Ischemic Cardiomyopathy • First randomized trial of surgical ventricular restoration + CABG vs CABG alone for ischemic cardiomyopathy was published April 2006 isure of Journal of Cardiac Failure Journal of Cardiac Failure Vol 12 No 3 2006

49. LV Reconstruction for Ischemic Cardiomyopathy • 74 Consecutive patients with ischemic cardiomyopathy and EF < 35% with LESV > 80ml/m2

50. LV Reconstruction for Ischemic Cardiomyopathy • Limitations • Non-Blinded • Excluded > 2+ MR or other significant valvular heart disease • Dyskinetic ant wall • Non-viable Ant wall on Thallium testing