Transcript of End-Stage Heart Failure: Surgical Options ischemia (CABG) mitralis insuf. (RMA) "Dor" aneurysmectomy...
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- End-Stage Heart Failure: Surgical Options ischemia (CABG)
mitralis insuf. (RMA) "Dor" aneurysmectomy Surgical Ventricular
Restoration mechanical /assistance replacement HTX REPAIR RESHAPE
REPLACE
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- Systolic restrictive motion
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- > 30 > 0.2 IMR RV (ml) > 60 ERO (cm 2 ) >
0.4ORGANIC ECHO CRITERIA OF SEVERE MR M. Enriquez-Sarano
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- Restrictive Mitral Annuloplasty: two sizes under
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- Postoperative echo result
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- 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
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- Patient characteristics EACTS 15/09/04 Jan 2000 March 2004 87
patients age 66 10 yrs NYHA 3.0 0.9 III / IV: 82 % log
EuroSCORE11.0 10.8 previous CABG7 %
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- Baseline echocardiography MR grade3.1 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
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- Surgery median annuloplasty ring size26 CABG86 % mean distal
anastomoses3.3 1.3 CPB time (min)189 52 Ao-clamp (min)125 37 EACTS
15/09/04
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- Results (1) Time (years) 543210 Cumulative Survival
1,0,9,8,7,6,5,4,3,2,1 0,0 Early mortality 8.0 % (n=7) Late
mortality 7.5 % (n=6) 87 65 43 25 9
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- Results (3) Baseline3.1 0.5 Coaptation height 8 1 mm MV
diastolic gradient 2.4 0.6 mmHg EACTS 15/09/04 Mitral regurgitation
Early 0.4 0.3 Late 0.6 0.6
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- Results (4) LVESD (mm) Baseline52 8 Late FU 44 11 EarlyLateNo
reverse remodeling 40% 33% 27% (p < 0.01)
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- Results (5) LVEDD (mm) Baseline64 8 Late FU 58 10 EACTS
15/09/04 42% 22% 36% EarlyLate No reverse remodeling (p <
0.01)
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- LVESD and Reverse Remodeling LVESD (mm) specificity sensitivity
81 % 51 EACTS 15/09/04
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- LVEDD (mm) specificity sensitivity 89 % 65 LVEDD and Reverse
Remodeling EACTS 15/09/04
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- RESULTS PRE-MVPPOST-MVP LVEDD65 mm53 mm LVESD49 mm32 mm LA43
mm35 mm MVA2.2 cm 2 Mean gradient2.8 mmHg
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- 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
Long-Term Durability after restrictive MVP
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- PRE POST (note: MI jet)(note: restrictive ring) Long-Term
Durability after restrictive MVP
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- PREPOSTp-value LAEDV (ml)87 2690 300.98 LAESV (ml)152 34142
370.08 LVEDV (ml)219 45157 280.001 LVESV (ml)90 4559 240.08 LVEF
(%)36 1053 80.01 LV Mass (g)137 49125 230.32 Long-Term Durability
after restrictive MVP
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- 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
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- Restrictive Mitral Annuloplasty in Non-ischemic Dilating
Cardiomyopathy 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
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- Patient Characteristics 02/02/05 July 2000 March 2004 29
patients6 RMA + CorCap 23 RMA
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- Baseline echocardiography MR grade3.7 0.5 3+ / 4+ : 100 % LVESD
(mm)62 10 LVEDD (mm)74 11 02/02/05
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- Surgery mean annuloplasty ring size26 2 size 24 : n = 10 TVP12
( 52 %) TEE coaptation (mm) 8 1 CPB time (min)120 27 Ao-clamp (min)
70 21 02/02/05
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- Results (1) POD 3: F 63 y NYHA III LV 73 / 63 RMA 26 postop
tamponade persisting AF IABP CVVH - MOF Early mortality 8.6 %
(n=2)
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- Results (3) Late mortality 14.2 % (n=3) 10 mo :VF resuscitation
18 mo :collapse 27 mo :septicaemia 02/02/05
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- Results (4) Clinical follow-up ( 27 13 months) NYHA3.3 0.5 1.7
0.6 2 13 3 0 5 17 6 2 10 3 1 2 4 1 I II III IV death 02/02/05
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- Results (5) Follow up17 9 months MR 0.7 0.9 1 MR grade 2 1 MR
grade 3 LVEDD (mm)75 9 mm64 10 LVESD (mm)62 9 mm58 13
Echocardiography 02/02/05
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- CorCap NVT 08/10/04
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- PATIENTS Nov 2002 June 2005: 25 pts age (y)62.5 (34-76) males17
NYHA 3.4 EuroSCORE14 LVEF (%)22 (15-26) LUMC 06-05
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- Concomitant Procedures MVP24 TVP19 AF ablation 4 CABG 5 AVR 1
CPB (min) 128 + 23 X clamptime (min) 66 + 21 LUMC 06-05
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- Echocardiography LUMC 06-05 Pre-opDischargeFollow-up (6 m)
MR3.10.30.7 LVEDD (mm) 72.769.668.3 LVESD (mm) 62.56162
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- 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 1 Department of Cardiothoracic Surgery, 2
Department of Cardiology Leids Universitair Medisch Centrum
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- 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
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- Surgical procedure according to DOR Fontan stitch sizing of
residual LV using a saline-filled balloon (55 ml / m 2 BSA)
elliptical shape !
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- Dor / SVR
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- 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%)
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- Mortality / morbidity Hospital mortality10,3% Post-operative
complications peri-operative MI0% postoperative IABP26% bleeding
needing reoperation3% CVA3% dialysis8% 1 pre-op chronic
dialysis
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- Echocardiographic data Pre-operativePost-operativep-value LVEF
(%)20.5 6.433.9 9.8 65 < 80:RMA + CorCap RMA + "Dor" > 80:HTX
SVR (+ RMA)" title="The "Leiden Algorithm" Preop LVEDD < 65:RMA
> 65 < 80:RMA + CorCap RMA + "Dor" > 80:HTX SVR (+
RMA)">
- The "Leiden Algorithm" Preop LVEDD < 65:RMA > 65 <
80:RMA + CorCap RMA + "Dor" > 80:HTX SVR (+ RMA)
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- Reversible cause? No Correction Recovery Follow Up NON-ISCHEMIC
(medication+ lifestyle) No complete recovery RESYNCHRONIZATION?
Significant Valve disease? Indication SVR? Valve surgery + SVR
Valve surgery CorCap Yes No Indication SVR? Yes No INVASIVE
SURGERYREVASCULARISATION/SURGERY No ISCHEMIC Ischemia and/or
viability? AP and significant CAD? CABG + valve-surgery Significant
Valve disease? CABG + SVR/Dor + valve surgery Indication LV-
reconstruction? SVR/Dor Indication LV- reconstruction? Valve
surgery + SVR/Dor Indication SVR/Dor? Significant Valve disease?
CABG + SVR/Dor PCI or CABG Yes No Yes No Valve surgery ( CorCap) No
Yes Indication SVR? Yes No FOLLOW UP Yes MISSION! HF
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- INVASIVE MISSION! HF REVASCULARISATION/SURGERY ISCHEMIC
Ischemia and/or viability? AP and significant CAD? CABG +
valve-surgery Significant Valve disease? CABG + SVR/Dor + valve
surgery Indication LV- reconstruction? SVR/Dor Indication LV-
reconstruction? Valve surgery + SVR/Dor Indication SVR/Dor?
Significant Valve disease? CABG + SVR/Dor PCI or CABG Yes No Yes No
Valve surgery ( CorCap) No Yes Indication SVR? Yes No FOLLOW UP Yes
RESYNCHRONIZATION?
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- Reversible cause? No CorrectionRecovery Follow Up NON-ISCHEMIC
(medication+ lifestyle) No complete recovery RESYNCHRONIZATION?
Significant Valve disease? Indication SVR? Valve surgery + SVR
Valve surgery CorCap Yes No Indication SVR? Yes No INVASIVE SURGERY
No FOLLOW UP MISSION! HF
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- SCREENING & ETIOLOGY History NYHA class Examination LAB ECG
X-ray Chest TTE Further analysis Chronic heart failure? No LVEF
< 40% NYHA III or IV Exercise testing with VO2 max Myoview
stress and rest, FDG CAG (left & right) 24 hour Holter
monitoring additional LAB QOL score + 6 min. walk test Old
myocardial infarction and/or 1 coronair with > 50% stenosis? Yes
ISCHEMIC causeNON-ISCHEMIC cause No LAB NT-proBNP Complete blood
count ESR, CRP Electrolytes, Creat, BUN Liver panel Lipid profile
TSH, fT4 Glucose Yes No Yes THERAPY Further analysis
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- MISSION! HF BASIS NYHA I Continue medication(!), lower dosis
diuretics NYHA II Atrial fibrillation VR > 100: Digoxine
Diuretics ACE-inhibitor eta blocker + + Thiazide 1 dd when mild HF
and clearance > 30 - start ATB in case of ACE-intolerance -
c.i.: potassium > 5.5, dubbelsided renal arterystenosis - raise
every 2 weeks untill (individual) maximum Persisting low potassium:
start spironolacton 1 dd 12.5 mg or Inspra 1 dd 12.5 mg
Loopdiuretics 1 dd Loopdiuretics 2 dd - start when no signs of
decompensation - raise every 2 weeks until (individual) maximum
Loopdiuretics 2 dd + Thiazide Nitrate in case of orthopnoea
Consider Nitrate i.c.w. Hydralazine in case of ACE-intolerance
Spironolacton 1dd 25 mg - in case of gynaecomasty: eplerenone 1 dd
25-50 mg - c.i.: potassium > 5.0, Creat > 250 - if needed,
consider ATB in stead of spironolacton NYHA III or IV NYHA IV
Digoxin (sinusrhythm) NYHA III MEDICATION
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- MISSION! HF RESYNCHRONIZATION? Biventricular ICD FOLLOW UP EF
< 30% VF or haemodynamic unstable VT ICD EF 30 - 40 % + VT/NSVT
EFO Indication HTx? Stemcell therapy? ICD When pre-operative: LVEF
40 or QRS > 120ms: - epicardial LV-lead peri- operative -
post-operative biventricular ICD When pre-operative: - LVEF <
30%: ICD post-operative - LVEF > 30% + (NS)VT: EFO + ICD When
surgery waitinglist is long and (biv) ICD indication: consider
(biv) ICD implantation pre- operatively SL delay > 40 ms (EF
< 30% + NYHA III or IV) Yes No SCD RISK ASSESSMENT
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- MISSION! HF FOLLOW UP and RE-EVALUATION Month 3 + Month 9 Week
2-3 AFTER INVASIVE PROCEDURE DOCTOR + HF nurse History, NYHA class
Examination LAB ECG TTE (only Month 3 visit) HF nurse History, NYHA
class Examination LAB (incl. NT-proBNP) ECG REGULAR FOLLOW UP Month
6 + Month 12 DOCTOR + HF nurse HF nurse History, NYHA class
Examination LAB (incl. NT-proBNP) ECG QOL + 6 min. walk test
Exercise + VO2max TTE Only month 12 visit: 24 hour holter
RE-EVALUATION Every year or worsening NYHA When appropriate,
re-evaluate indication for: - revascularisation - valve / LV
surgery - resynchronization therapy - ICD - HTx - stemcell therapy
every 3 months DOCTOR + HF nurse History, NYHA class Examination
LAB (incl. NT-proBNP) ECG Exercise + VO2max TTE LUMC every year OWN
CARDIOLOGIS T NYHA class III / IV NYHA class I / II History, NYHA
class Examination LAB ECG DOCTOR + HF nurse History, NYHA class
Examination LAB (incl. NT-proBNP) ECG TTE Exercise + VO2max QOL + 6
min. walk test Holter (CAG) ( Myoview) PRE-OP 2 weeks before
surgery HF nurse History, NYHA class Examination LAB ECG
RE-EVALUATION DOCTOR every 6 months History, NYHA class Examination
LAB ECG
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- Acute hemodynamic effects of restrictive mitral annuloplasty in
patients with end-stage heart failure S.A.F. Tulner, P. Steendijk,
R.J.M. Klautz, J.J. Bax, M.I.M. Versteegh, E.E. van der Wall,
R.A.E. Dion J Thorac Cardiovascular Surgery (in press) Departments
of Cardio-Thoracic Surgery and Cardiology Leiden University Medical
Center
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- Results: typical example of RMA
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- Control group Unchanged systolic function Improved active
relaxation, increased diastolic chamber stiffness Restrictive
Mitral Annuloplasty No significant acute effects on global, and
intrinsic systolic function Alterations in diastolic function
appear similar to the control group Conclusions