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End-Stage Heart Failure: Surgical Options

ischemia (CABG) mitralis insuf. (RMA) "Dor" aneurysmectomy S urgical V entricular R estoration mechanical /assistance replacement HTX. End-Stage Heart Failure: Surgical Options. REPAIR. RESHAPE. REPLACE. Systolic restrictive motion. ECHO CRITERIA OF SEVERE MR. ORGANIC. ERO (cm 2 )

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End-Stage Heart Failure: Surgical Options

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  1. ischemia (CABG) mitralis insuf. (RMA) "Dor" aneurysmectomy Surgical Ventricular Restoration mechanical /assistance replacement HTX End-Stage Heart Failure: Surgical Options REPAIR RESHAPE REPLACE

  2. Systolic restrictive motion

  3. ECHO CRITERIA OF SEVERE MR ORGANIC ERO (cm2) > 0.4 RV (ml) > 60 IMR >0.2 > 30 M. Enriquez-Sarano

  4. Restrictive Mitral Annuloplasty: two sizes under

  5. Postoperative echo result

  6. Restrictive Annuloplasty for Ischaemic Mitral Regurgitation results in Reverse Left Ventricular Remodeling J. Braun, J.J. Bax, M.I.M. Versteegh, P.G. Voigt, E.R. Holman, R.J.M. Klautz, R.A.E. Dion Departments of Cardiothoracic Surgery and Cardiology, Leids Universitair Medisch Centrum

  7. Patient characteristics Jan 2000 – March 2004 87 patients age 66 ± 10 yrs NYHA 3.0 ± 0.9 III / IV: 82 % log EuroSCORE 11.0 ± 10.8 previous CABG 7 % EACTS 15/09/04

  8. Baseline echocardiography MR grade 3.1 ± 0.5 3+ / 4+ : 81 % LA size (mm) 54 ± 6 LVESD (mm) 52 ± 8 LVEDD (mm) 64 ± 8 LVEF (%) 32 ± 10 EACTS 15/09/04

  9. Surgery median annuloplasty ring size 26 CABG 86 % mean distal anastomoses 3.3 ± 1.3 CPB time (min) 189 ± 52 Ao-clamp (min) 125 ± 37 EACTS 15/09/04

  10. Results (1) 1,0 Early mortality 8.0 % (n=7) ,9 ,8 CumulativeSurvival ,7 Late mortality 7.5 % (n=6) ,6 ,5 ,4 ,3 ,2 87 65 43 25 9 ,1 0,0 0 1 2 3 4 5 Time (years)

  11. Results (3) Mitral regurgitation Baseline 3.1 ± 0.5 Coaptation height 8 ± 1 mm MV diastolic gradient 2.4 ± 0.6 mmHg Early 0.4 ± 0.3 Late 0.6 ± 0.6 EACTS 15/09/04

  12. 27% 33% 40% Early Late No reverse remodeling Results (4) LVESD (mm) Baseline 52 ± 8 Late FU 44 ± 11 (p < 0.01)

  13. 22% 42% 36% No reverse remodeling Early Late Results (5) LVEDD (mm) Baseline 64 ± 8 Late FU 58 ± 10 (p < 0.01) EACTS 15/09/04

  14. 81 % 51 LVESD and Reverse Remodeling specificity sensitivity LVESD (mm) EACTS 15/09/04

  15. 89 % 65 LVEDD and Reverse Remodeling specificity sensitivity LVEDD (mm) EACTS 15/09/04

  16. RESULTS

  17. Long-Term Durability after restrictive MVP • 11 patients MRI pre-surgery and follow-up MRI • 7 men / 4 women • mean age ± SD: 53 ± 14 years • mean follow-up period ± SD: 42 ± 7 months

  18. Long-Term Durability after restrictive MVP PRE POST (note: MI jet) (note: restrictive ring)

  19. Long-Term Durability after restrictive MVP

  20. Conclusions RMA + CABG yield reverse remodeling Preoperative LV dimensions limit extent of reverse remodeling Additional techniques may be needed when LVEDD > 65 EACTS 15/09/04

  21. Restrictive Mitral Annuloplasty in Non-ischemic Dilating Cardiomyopathy J. Braun, J.J. Bax, M.I.M. Versteegh, P.G. Voigt, E.R. Holman, R.J.M. Klautz, R.A.E. Dion Departments of Cardiothoracic Surgery and Cardiology, Leids Universitair Medisch Centrum

  22. Patient Characteristics July 2000 – March 2004 29 patients 6 RMA + CorCap 23 RMA 02/02/05

  23. Baseline echocardiography MR grade 3.7 ± 0.5 3+ / 4+ : 100 % LVESD (mm) 62 ± 10 LVEDD (mm) 74 ± 11 02/02/05

  24. Surgery mean annuloplasty ring size 26 ± 2 size 24 : n = 10 TVP 12 ( 52 %) TEE coaptation (mm) 8 ± 1 CPB time (min) 120 ± 27 Ao-clamp (min) 70 ± 21 02/02/05

  25. Results (1) Early mortality 8.6 % (n=2) POD 3 : F 63 y – NYHA III – LV 73 / 63 RMA 26 postop tamponade – persisting AF IABP – CVVH - MOF

  26. Results (3) Late mortality 14.2 % (n=3) 10 mo : VF – resuscitation 18 mo : collapse 27 mo : septicaemia 02/02/05

  27. Results (4) Clinical follow-up ( 27 ± 13 months) NYHA 3.3 ± 0.5 1.7 ± 0.6 2 I II III IV death 2 13 10 3 17 1 3 2 0 6 4 1 5 02/02/05

  28. Results (5) Echocardiography Follow up 17 ± 9 months MR 0.7 ± 0.9 1 MR grade 2 1 MR grade 3 LVEDD (mm) 75 ± 9 mm 64 ± 10 LVESD (mm) 62 ± 9 mm 58 ± 13 02/02/05

  29. CorCap™ NVT 08/10/04

  30. PATIENTS Nov 2002 – June 2005: 25 pts age (y) 62.5 (34-76) males 17 NYHA 3.4 EuroSCORE 14 LVEF (%) 22 (15-26) LUMC 06-05

  31. Concomitant Procedures MVP 24 TVP 19 AF ablation 4 CABG 5 AVR 1 CPB (min) 128 + 23 X clamptime (min) 66 + 21 LUMC 06-05

  32. Echocardiography LUMC 06-05

  33. Left ventricular restoration in ischemic congestive heart failure: The Leiden Experience Klein P.1, Versteegh M.I.M.1, Klautz R.J.M.1, de Weger A.1, Tavilla G.1, Holman E.R.2, Bax J.J.2, Dion R.A.E.1 1Department of Cardiothoracic Surgery, 2Department of Cardiology Leids Universitair Medisch Centrum

  34. Study population (I) • 39 patients with ICHF • 30 males, mean age 62 ± 11 years • NYHA-class 3.1 ± 0.5 • LVEF 20.5 ± 6.4% • median interval after infarction 36 months (1-240) • EuroSCORE 14 ± 13 • 5 patients were operated in emergency (13%) • 2 pre-op IABP • 1 pre-op ventilation • 1 acute infarction

  35. Surgical procedure • according to DOR • Fontan stitch • sizing of residual LV using a saline-filled balloon (55 ml / m2BSA) • elliptical shape !

  36. Dor / SVR

  37. Concomitant procedures • CABG in 28 patients (72%) • Mean number of distal anastomoses 2.4 ± 1.2 • Restrictive mitral annuloplasty in 25 patients (64%) • Mean ring size 26 ± 2 • Tricuspid annuloplasty 10 (26%) • VT-ablation 1 (3%) • VSR-repair 1 (3%)

  38. Mortality / morbidity Hospital mortality 10,3% Post-operative complications peri-operative MI 0% postoperative IABP 26% bleeding needing reoperation 3% CVA 3% dialysis 8% • 1 pre-op chronic dialysis

  39. Echocardiographic data

  40. LVR and mitral valve repair Apical four chamber view before restoration

  41. LVR and mitral valve repair Apical four chamber. Note the patch at the apical region and the improved contraction.

  42. Results: RMA + DOR + CABG

  43. Sustained left ventricular reverse remodeling, improved systolic function and unchanged diastolic function six months after surgical ventricular restoration S.A.F. Tulner, P. Steendijk, R.J.M. Klautz, J.J. Bax, P.Oemrawsingh, H.F. Verwey, M.J. Schalij, E.E. van der Wall, R.A.E. Dion Departments of Cardio-Thoracic Surgery and Cardiology Leiden University Medical Center

  44. Clinical results • ICU stay 6 days (1-35) • Hospital stay 14 days (8-47) • Mean follow-up 13 ± 10 months • Late mortality 11.4% (4 patients)CHF 2 (+10mo, +1mo) Cancer 1, CVA 1 • Mean NYHA at follow-up 1.1 ± 0.3

  45. NYHA class Pre Post I 0 30 23 7 II 0 0 1 III 28 0 11 IV 4 4 8 Death

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