In the name of GOD

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Treatment of End Stage Heart Treatment of End Stage Heart FailureFailure

Surgical TreatmentsSurgical Treatments

Cardiac Resynchronization Cardiac Resynchronization Treatment(CRT) Treatment(CRT)

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Surgical Treatment of Heart Surgical Treatment of Heart FailureFailure

CABGs in ischemic cardiomyopathyCABGs in ischemic cardiomyopathy

Mitral valve repair in patients with dilated Mitral valve repair in patients with dilated cardiomyopathycardiomyopathy

Surgical Ventricular reconstruction(Dor Surgical Ventricular reconstruction(Dor procedure)procedure)

Passive Cardiac support DevicePassive Cardiac support Device

Heart TransplantationHeart Transplantation

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Dor procedure for Ischemic Dor procedure for Ischemic CardiomyopathyCardiomyopathy

Purse string stitch around a nonviable scarred aneurysm to Purse string stitch around a nonviable scarred aneurysm to minimize the excluded area. The residual defect is minimize the excluded area. The residual defect is sometimes covered by a patch made from Dacron, sometimes covered by a patch made from Dacron, pericardium, or an autologous tissue flappericardium, or an autologous tissue flap 44

Dor procedure for Ischemic Dor procedure for Ischemic CardiomyopathyCardiomyopathy

The operation shortens the long axis, but leaves the The operation shortens the long axis, but leaves the short axis length unchanged, producing an increase short axis length unchanged, producing an increase in ventricular diastolic sphericity while the systolic in ventricular diastolic sphericity while the systolic shape becomes more ellipticalshape becomes more elliptical 55

CardiomyoplastyCardiomyoplasty

Cardiomyoplasty, also referred to as Cardiomyoplasty, also referred to as "dynamic cardiomyoplasty," "dynamic cardiomyoplasty,"

Surgical therapy for dilated Surgical therapy for dilated cardiomyopathy in which the latissimus cardiomyopathy in which the latissimus dorsi muscle is wrapped around the heart dorsi muscle is wrapped around the heart and paced during ventricular systole. and paced during ventricular systole.

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Carpentier peformed the first successful Carpentier peformed the first successful surgery on a humen in 1985surgery on a humen in 1985

CardiomyoplastyCardiomyoplasty

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Considered Criteria for Surgical Considered Criteria for Surgical RepairRepair

Anteroseptal MI, with dilated left ventricle Anteroseptal MI, with dilated left ventricle (end-diastolic volume index >100 mL/m2)(end-diastolic volume index >100 mL/m2)

Depressed LVEF Depressed LVEF

Left ventricular regional dyskinesis or Left ventricular regional dyskinesis or akinesis >30 percent of the ventricular akinesis >30 percent of the ventricular perimeter, and perimeter, and

Either symptoms of angina, heart failure, Either symptoms of angina, heart failure, or arrhythmias or arrhythmias

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The following are considered to be relative The following are considered to be relative contraindicationscontraindications

Systolic pulmonary artery pressure >60 Systolic pulmonary artery pressure >60 mmHg mmHg

Severe right ventricular dysfunction Severe right ventricular dysfunction

Regional dyskinesis or akinesis without Regional dyskinesis or akinesis without dilation of the ventricle dilation of the ventricle

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LV Reconstruction for Non-LV Reconstruction for Non-ischemic Cardiomyopathyischemic Cardiomyopathy

Cardiomyoplasty experience has led to Cardiomyoplasty experience has led to other novel approaches to heart failure. other novel approaches to heart failure.

Observations suggested that some Observations suggested that some patients benefited from the diastolic patients benefited from the diastolic "girdling" effect of the muscle wrap "girdling" effect of the muscle wrap

This observation led to the development of This observation led to the development of the Acorn device and Myosplintthe Acorn device and Myosplint

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LV Reconstruction for Non-LV Reconstruction for Non-ischemic Cardiomyopathyischemic Cardiomyopathy

Acorn device Acorn device knitted polyester sock knitted polyester sock that is drawn up and that is drawn up and anchored over the anchored over the ventricles in order to limit ventricles in order to limit left ventricular dilation left ventricular dilation Preliminary data suggest Preliminary data suggest that the device produces that the device produces an improvement in heart an improvement in heart failure symptoms, LVEF, failure symptoms, LVEF, left ventricular end-left ventricular end-diastolic dimension, and diastolic dimension, and quality of lifequality of life

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INTRODUCTIONINTRODUCTION

Heart transplantation remains the ultimate Heart transplantation remains the ultimate treatment for heart failuretreatment for heart failure

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HEART TRANSPLANTATIONHEART TRANSPLANTATIONACTUARIAL SURVIVAL (1982-2000)

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Years Post-Transplantation

Sur

viva

l (%

)

N=52,195

Half-life =9.1 yearsConditional Half-life = 11.6 years

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Who Should Not Be OfferedWho Should Not Be Offereda Heart Transplant?a Heart Transplant?

Irreversible PHTN or pulmonary Irreversible PHTN or pulmonary parenchymal diseaseparenchymal diseaseIrreversible renal or hepatic dysfunctionIrreversible renal or hepatic dysfunctionSevere peripheral or cerebrovascular Severe peripheral or cerebrovascular diseasediseaseIDDM with end-organ damageIDDM with end-organ damageCoexisting cancerCoexisting cancerNon-compliance, addictionNon-compliance, addictionElderly patients (aprox > 70yo)Elderly patients (aprox > 70yo)

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Intraaortic Balloon Pump (IABP)Intraaortic Balloon Pump (IABP)

Provides temporary Provides temporary circulatory assistancecirculatory assistance– ↓ ↓ Afterload Afterload – Augments aortic Augments aortic

diastolic pressurediastolic pressure

OutcomesOutcomes– Improved coronary Improved coronary

blood flowblood flow– Improved Improved

perfusion of vital perfusion of vital organsorgans

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Ventricular Assist Devices Ventricular Assist Devices (VADs)(VADs)

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Ventricular Assist Devices (VADs)

• Indications for VAD therapy• Postcardiotomy cardiogenic shock

• Bridge to recovery or cardiac transplantation

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Left ventricular assist device

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Cardiac Resynchronization Cardiac Resynchronization Therapy for Heart FailureTherapy for Heart Failure

Patient Selection Patient Selection and Clinical Outcomesand Clinical Outcomes

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CRT-Cardiac Resynchronization

TherapyTherapyHOW IT WORKS:

Standard implanted pacemakers - equipped with two wires (or "leads") conduct pacing signals to specific regions of heart (usually at positions A and C). Biventricular pacing devices have added a third lead (to position B) that is designed to conduct signals directly into the left ventricle. Combination of all three lead > synchronized pumping of ventricles, inc. efficiency of each beat and pumping more blood on the whole.

 

 

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Ventricular DysynchronyVentricular Dysynchrony

Abnormal ventricular conduction resulting Abnormal ventricular conduction resulting in a mechanical delayin a mechanical delay– Wide QRS (IVCD); typically LBBB morphologyWide QRS (IVCD); typically LBBB morphology

– Poor systolic functionPoor systolic function

– Impaired diastolic functionImpaired diastolic function

ECG depicting interventricular conduction delayECG depicting interventricular conduction delay

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Cardiac Resynchronization Cardiac Resynchronization TherapyTherapy

GoalsGoals

Improve hemodynamicsImprove hemodynamics

Improve Quality of LifeImprove Quality of Life

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Cardiac Resynchronization Cardiac Resynchronization TherapyTherapy

Cardiac resynchronization, Cardiac resynchronization, in association with an in association with an optimized AV delay, optimized AV delay, improves hemodynamic improves hemodynamic performance by forcing the performance by forcing the left ventricle to complete left ventricle to complete contraction and begin contraction and begin relaxation earlier, allowing relaxation earlier, allowing an increase in ventricular an increase in ventricular filling time.filling time.

Coordinate activation of the Coordinate activation of the ventricles and septum.ventricles and septum.

ECG depicting cardiac resynchronizationECG depicting cardiac resynchronization

ECG depicting IVCDECG depicting IVCD

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Transvenous ApproachTransvenous Approach– Standard pacing leads in RA and RVStandard pacing leads in RA and RV

– Specially designed left heart lead placed in a left ventricular cardiac vein via Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinusthe coronary sinus

Achieving Cardiac Achieving Cardiac ResynchronizationResynchronization

Mechanical Goal: Pace Right and Left VentriclesMechanical Goal: Pace Right and Left Ventricles

Cardiac Resynchronization SystemCardiac Resynchronization System

MIRACLE Study PopulationMIRACLE Study PopulationSymptomatic patients with heart failureSymptomatic patients with heart failure

18 years of age18 years of age

NYHA Functional Class III or IVNYHA Functional Class III or IV

QRS duration QRS duration 130 msec 130 msec

LVEF LVEF 35% by echocardiography 35% by echocardiography

LVEDD LVEDD 55 millimeters (echo measure) 55 millimeters (echo measure)

Stable HF medical regimen for Stable HF medical regimen for 1-month 1-month– ACE-I or substitute, if toleratedACE-I or substitute, if tolerated– β-blocker - stable regimen for β-blocker - stable regimen for 3-months 3-months

Abraham WT, et al. Journal of Cardiac Failure 2000; Vol 6 No. 4.Abraham WT, et al. Journal of Cardiac Failure 2000; Vol 6 No. 4.

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THANKS FOR YOUR ATTENTION

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