Review: Surgery for Heart Failure

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ReviewSurgery for Heart Failure

• Ian Ramnarine
• Cardiac Surgical Research Fellow

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Background

• End-stage Heart Failure
• Deaths from CCF
• Cardiac Rehabilitation
• Pharmacotherapy
• Percutaneous Intervention
• Surgery

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Heart transplants by year
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PharmacotherapyNew Old Drugs

• ACE Inhibitors
• Statins
• Beta-blockers
• Spironolactone

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Percutaneous Intervention

• PTCA
• Balloon Angioplasty
• Stents
• Drug-eluting stents
• Alcohol injection for HOCM
• Trans-myocardial Revascularization

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Surgery

• Coronary Revascularization
• Valvular Surgery
• Ventricular Reconstruction for Ischaemic
  Cardiomyopathy
• Mitral Repair for Regurgitation
• LV Aneurysm Plication/Resection
• Ventricular Remodelling
• Post-infarct VSD repair

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Ischaemic Cardiomyopathy

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LV Aneurysm Plication/Resection

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Batista Operation



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Nair Operation
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Cellular Mechanisms

• Genetherapy
• Cellular Cardiomyoplasty
• Immunoregulation in Transplantation
• Tissue Engineering (valves)

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Cellular Cardiomyoplasty

• HF when a critical number of cardiomyocytes
  irreversibly lost
• Function improved with new cells
• Islet cell implantation

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Cellular Cardiomyoplasty

• Optimal type of donor cells
• Mechanism by which cell engraftment improves
  cardiac function
• Optimization of cell survival
• Potential benefits of cell transplantation in
  non-ischemic heart failure

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Evidence

• Grafted neonatal cardiomyocytes detectable in
  infarcted areas 6/12 post-transplantation
• Sino-Atrial Fetal cells trigger pacemaker
  activity when conduction system damaged

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Issues

• Ethics
• Availability
• Antigenicity
• Major risk
• Tumor development
• Arrhythmias

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Skeletal myoblasts

• Elastic properties
• Direct contribution of grafted cells to improved
  systolic function
• Paracrine effects
• Modulates injury response

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Bone marrow stem cells

• Different cell populations
• Pre-treated mesenchymal cells
• CD34 and AC133

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Clinical trail

• 10 patients
• vastus lateralis biopsy and cells prepared and
  cultured
• Injection CABG
• postoperative arrhythmias

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Surgery Circulatory Support

• Transplantation
• Mechanical Assist
• Biological Assist
• Ventricular Containment

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Surgery Circulatory Support

• Transplantation
• Mechanical Assist
• Cardiac Support
• Implantable IABP
• Ventricular Assist Devices
• Total Artificial Heart
• Axial Flow Pump
• Biological Assist
• Cardiomyoplasty
• Skeletal Muscle Ventricle
• Ventricular Containment

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Ventricular containment

• Cardiomyoplasty
• ACORN net
• Myosplint

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Acorn Cardiac Support Device
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CSD and Concommitant Proc
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Myosplint
Change in radius
R1
R2
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Myosplint Clinical trial

• 4 patients with Myosplint
• 4 patients with Myosplint MVR
• Symptomatic results unequivocal
• No device related complications

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Mechanical assist devices

• Principles
• Direct systolic augmentation of the heart,
• Mechanical pumping to divert blood from the left
  atrium/ventricle directly into the aorta with
  sufficient force to maintain normal arterial
  pressure,
• Diastolic augmentation

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Mechanical assist devices

• Pulsatile
• Heartmate, LionHEART
• Axial
• Bearings
• Jarvik 2000, Heartmate II
• No Bearings
• Heartmate III

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Implantable IABP

• The Kantrowitz CardioVADTM (KCV)
• 60cc pumping chamber
• Percutaneous access device (PAD),
• External controller
• Clinical trials
• 5 men (age 59 to 73)

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Results

• Patient 1 died intra-operatively
• 1 month
• cardiac index increased (1.7 to 2.6 L/min/m2)
• decreases in creatinine (2.6 to 1.5 mg/dL)
• PCWP dec 32 to 14 mm Hg
• RA dec 19 to 9 mm Hg
• NYHA class improved (IV to II)

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Ventricular Assist Devices

• Timing of LVAD intervention
• Bridge-to-transplant or to-recovery
• REMATCH Trial

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Indication for Use

• Nov 2002
• FDA approved
• Bridge-to-transplant
• Destination therapy

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REMATCH Trial

• 129 patients
• End-stage heart failure
• NOT eligible for transplantation
• LVAD 68 patients
• Optimal medical management (61).

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Results

• 48 dec in risk of death from any cause in LVAD
  group
• Survival at one year 52 VS 25 (P0.002)
• Two years 23 VS 8 (P0.09)
• Adverse events risk in the device group was 2.35
  times

Infection, bleeding, and device malfunction
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Conclusions

• LVAD in advanced heart failure
• clinically meaningful survival benefit
• improved quality of life
• An acceptable alternative therapy in selected
  patients
• Not in candidates for cardiac transplantation

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Bridge-to-transplant
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Abiomed
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Heart Mate
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Lionheart LVAS

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Novocor LVAS
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Novocor LVAS

• 1461 worldwide
• Porcine valved conduit
• Solenoid coil
• Pusher plates

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Axial Flow Pump

• Jarvik 2000

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DeBakey VAD axial pump

• Eur J Cardiothorac Surg. 2002 Dec, Fabiani JN.
• 1999 to 2002 9 patients
• NYHA functional class IV
• bridge to transplantation
• LV apex to ascending aorta
• Mean support was 81/-62 (16-224 days).
• Eight reoperations (three for bleeding or
  cardiac tamponade, one for haemoperitoneum
• Hemolysis in two patients.
• No device infection or dysfunction
• Secondary recovery in six patients.
• Five patients were transplanted

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Rotary Blood Pump
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Rotary pump as RVAD
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Problems

• Materials
• Power supply
• Drive line
• Infection
• Thrombosis
• Haemorrhage
• Cost
• Availability

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Total Artificial Heart
Thoratec
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Thoratec
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Experience Worldwide

• 1999-2002
• 17 pateints
• All in whom Transplant contraindicated
• 3 early deaths
• 9 alive gt 1 year

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Biological Cardiac Assist

• Cardiomyoplasty
• Biomechanical Heart
• Aortomyoplasty
• Skeletal Muscle ventricle

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Skeletal Muscle Assist

• Can Skeletal Muscle Mimic Cardiac Muscle ?
• Power Output
• Fatigue Resistance
• Speed of contraction
• Longevity

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Cardiomyoplasty
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Cardiomyoplasty What went wrong?

• Stimulation Protocol
• Fast type converted to slow type
• Failure to show systolic improvement
• 2000 cases worldwide
• Medtronic stopped making stimulator
• Patients felt better
• Minimal survival benefit

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Aortomyoplasty
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The Biomechanical Heart
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Skeletal muscle ventricleGirsch, et alSheep
model
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Skeletal muscle ventricle
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The SMV
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The SMV
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SMV on
ECG
Endocardial Viability Ratio Mean Diastolic Press
X Diastolic Time
Mean Systolic Press X Syst Time
Stimulation
Aortic Pressure
Left Ventricular Work
SMV Pressure
LAD Flow
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SMV on
ECG
Stimulation
Aortic Pressure
Left Ventricular Work
SMV Pressure
LAD Flow
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SMV on
ECG
Assisted Beat
Stimulation
Aortic Pressure
Left Ventricular Work
SMV Pressure
LAD Flow
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Same animal IABP on
ECG
Aortic Pressure
LAD Flow
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Haemodynamic data from IABP use
Diastolic
n7, plt 0.01
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Diastolic
n7, plt 0.01
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Thank You