Francesco Santini

Division of Cardiac Surgery, IRCCS San Martino – ISTUniversity of Genova Medical School, Italy

Lo Scompenso Cardiaco Avanzato:la riparazione transcatetere della valvola mitrale,

l’assistenza meccanica,e….altro.

European Journal of Heart Failure 2007;9:684–694

A group of patients for whom symptoms limit daily life despite usual recommendedtherapies and for whom lasting remission into less symptomatic disease is unlikely.

Selected Prognostic Models in HF

Heart Failure Survival Score

Seattle Heart Failure Model

EVEREST Risk Model

EFFECT

ADHERE

ESCAPE Discharge Score

Left ventricular systolic dysfunction

Each year cardiovascular disease (CVD) causes over 4 million deaths in Europe and over 1.9 million deaths in the European Union (EU).

Just under half of all deaths from CVD in both men and women are from CHD

One in five men (20%) and over one in five women (22%) die from the disease;

From the: European Cardiovascular Disease Statistics (2012 ed.) British Heart Foundation Health Promotion Research Group - Department of Public Health, University of Oxford

Am J Cardiol 2002;90:101–107

Circulation. 2005;112[suppl I]:I-344–I-350

Preoperative evaluation of myocardial viability in this group of patients using PET scanning or dobutamine echocardiography might additionally improve outcomes of this surgical approach.

Circulation. 2008;117:103-114

Viability = dysfunctional myocardium subtended by diseased coronary arteries withlimited or absent scarring that therefore has the potential for functional recovery.

Myocardial stunning = dysfunction can persist for several hours after transientnonlethal ischemia but eventually is followed by full functional recovery.

Myocardial hibernation = Viable myocytes that are hypocontractile secondary toongoing ischemia; these myocytes remain poorly functional until the oxygen supplyand demand imbalance can be rectified, usually by revascularization.

[even extreme degrees of wall thinning do not necessarily indicate the absence ofviability]

Algorithms for identifying and treating patients withCAD and chronically dysfunctional but viable myocardium

Circulation. 2008;117:103-114

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European Heart Journal August 29, 2014

Symptoms and/or signs of congestive heart failurewith abnormal left ventricular function

(clinical examination and echocardiography)

CAD+ CAD-

Assess myocardial viabilitywith technique available

Investigate alternativeaetiologies (DCM, valve disease, etc.)

No evidence of viabilityor viability in <25% of LV

Presence of significant viabilityin segments subtented by

stenotic coronaries

Medical treatment,CRT, ICD, LVAD

Coronary revascularizationby PCI or CABG

Circulation. 2008;117:103-114

Off-pump CABG

To perform coronary surgery on a

beating heart

Heart-lung machine not used

Stabilizer / Shunts

Less overall “trauma”

? Complete revascularization

Prog Cardiovasc Dis 2011;54:115-131

Patients undergoing CABG for HF with LV dysfunction(EF<30%):- operative mortality ranges from 1.6% to 11%

[perioperative complication rate approaching 65% (54% cardiac in nature)]

- 5-year survival 60% - 80%- 10-year “ 40% - 80%

Improvement in:

- LVEF - NYHA FC- disabling angina- freedom from recurrence of HF - “ “ hospitalization for HF exacerbations - overall quality of life

Ischemic Cardiomyopathy

Secondary (functional) Mitral Regurgitation:The mitral valve structure is normal and valve incompetence is related to severeLV dysfunction (Ischemic / Non-Ischemic)

Annular dilatation

Loss of systolic annular contraction

Increased LV size

PM dysfunction

PM migration

Type IIIb : Restricted leafletmotion duringsystole

Type IIIb : Restricted leafletmotion duringsystole

MR begets MR

Persistent MR is associated with a poor prognosis

Circulation 2009;120:1474-1481

viable myocardium papillary muscle dyssynchrony < MV coaptation depth(reverse LV remod) (<60msec)

Beneficial effect of concomitant CABG and MVR:

Acceptable perioperative mortality of 0.8% to 11% , and declining.

5-year survival between 51% - 83%, and improving.

Concomitant CABG and MVR achieve superior reduction in MRthan CABG alone in moderate to severe MR.

Concomitant CABG and MVR have been associated with improved:- LVEF- LVESV /LVEDV, LV sphericity index- NYHA and QoL

….no studies, however, haveshown a clear survival benefit.

European Heart Journal (2012) 33, 2451–2496

http://circ.ahajournals.org

1. Annular dilatation and flattening

2. Papillary muscle (PM) dysfunction

3. Leaflet tethering

4. LV dysfunction, dilatation, and free wall kinetic abnormalities

5. Closing forces

Undersized (or ‘restrictive’) annuloplasty- complete, rigid , 3-D, asymmetric rings- coaptation length of at least 8 mm

Resection of the secondary chordae

Repositioning of the papillary muscle

Leaflet augmentation

Concomitant LV restoration procedureMV repair

Heart Fail Rev 2013

Heart Fail Rev 2013

LV restoration procedure

(

Anteroseptal MI, dilated LV (EDVi < 100mL/m2), depressed LVEF (<20%),LV regional dyskinesis or akinesis > 30% of ventricular perimeterangina, heart failure, arrhyhtmias, inducible ischemia

European Heart Journal(2013) 34, 1323–1334

The STICH trial design

hypothesis 1:added value of revascularization over OMT

hypothesis 2:the benefit of adding SVR to CABG

issue 3:the impact of determining myocardial viability prior to revascularization

Predictors of MR after repair

Nat. Rev. Cardiol. 9, 133–146 (2012)

Mitral Valve Replacement

Types of Prostheses: the choice has to be individualized

Excellent durability; Good overall performance (avoiding physical hazards)ü Age group 40 – 65 yearsLife-long anticoagulation (complication rate 0.3-6.8/100 pt-yr)Thromboembolic events, perivalv. leakage, hemolysis, endocarditisRisk of chronic warfarin

Elderly patients (>65 yrs) [in sinus rhythm (...)]Freedom from anticoagulationThromboembolic events, perivalvular leakage, endocarditisControindicated in chronic renal failureLimited durability [SVD] (more rapid degeneration < 45 yrs )

Circulation. 1999;100[suppl II]:II-90 –II-94Reduced systolic wall stress

- Complete

- Partial

J Thorac Cardiovasc Surg 2013;145:128-39

N Engl J Med 2014;370:23-32.

Prog Cardiovasc Dis 2011;54:115-131

- operative mortality ranges from 1% to 8%[perioperative complication: MI (2.5%), IABP (25%), dialysis (7.5%), bleeding (5%)]

- 5-year survival 50% - 70%

Improvement in:

- LVEF - NYHA FC- MR grade- ventricular sphericity- 6-minute walk time

Nonischemic Cardiomyopathy

G.A. 81aaM.R. 83aa

Percutaneous mitral valve repair using the MitraClip® device

N Engl J Med 2011;364:1395-406

Although percutaneous repair was less effective at reducing mitralregurgitation than conventional surgery, the procedure wasassociated with superior safety and similar improvements in clinicaloutcomes.

http://circ.ahajournals.org

Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364:1395-406.

Whitlow PL, Feldman T, Pedersen WR, et al. Acute and 12–month results with catheter-based mitral valve leaflet repair: the EVEREST II (EndovascularValve Edge-to-Edge Repair) High Risk Study. J Am Coll Cardiol. 2012;59:130-9.

Lim DS, Reynolds MR, Feldman T, et al. Improved functional status and quality of life in prohibitive surgical risk patients with degenerative mitralregurgitation following transcatheter mitral valve repair with the Mitra- Clip(R) system. J Am Coll Cardiol 2013

J Am Coll Cardiol 2013;62:e147–239

JACC 2014;64:172-81

OUTCOMES BY DMR AND FMR CAUSES

Both FMR and DMR causes were represented, with FMR present in the majority of patients (70.1%). DMR patients were older, on average, than FMR patients (by 9 years), but the 2 groups were otherwise comparable. Safety outcomes were similar between the 2 groups, and both of the groups experienced improvements in effectiveness measures.

COAPT

RESHAPE-HF 2

MITRA-France

MATTERHORN (F MR)

HIRIDE (D MR)

Improvements:• IM grade• NYHA Class • LV

remodeling• QoL

• Patient selection• Interdisciplinary Heart Team• Timing• Environment• Learning Curve• Hospital Center• Scientific Registries

Heart Transplantation is the “gold standard” treatment for CHF …albeit its inability to serve to the current demand.

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• Completamento dell’anastomosi atriale destra (tecnica standard)

The increasing routine use of ventricular assist devices (VADs) to keep patients aliveuntil heart transplantation paved the way to their clinical use as an establishedtreatment for end-stage heart failure (DT).

imbalance between supply and demand

European Society of Cardiology (ESC) guidelines for the use of LVAD therapy

Eur J Heart Fail 2012;14:803-69

The Destination Therapy SAGA

The Interagency Registry for Mechanically Assisted Circulatory Support(Intermacs) is a North American registry established in 2005 for patients who arereceiving mechanical circulatory support device therapy to treat advanced heartfailure.

Intermacs was established as a joint effort of :

National Heart, Lung and Blood Institute (NHLBI), Food and Drug Administration (FDA), Centers for Medicare and Medicaid Services, Clinicians, Scientists,Industry representatives.

University of Alabama at Birmingham

www.uab.edu/medicine/intermacs

J Heart Lung Transplant 2009;28:535–41

Pulsatile / Volume Displacement

Varying the rate can increase flow/output and change ventricular dimension and volume

Continuous / Rotary

Varying the speed of the rotor can increase flow/output and change ventricular dimension and volume

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Heart Mate III (HM II) (Thoratec Inc.USA/St Jude)) Berlin Heart Incor (Berlin Heart AG, Germany) DuraHeart (Terumo, USA) HeartWare Ventricular Assist System (HeartWare Inc. USA)

continuous centrifugal-flow pump

Curr Opin Cardiol 2013, 28:223–233

Curr Opin Cardiol 2013, 28:223–233

In recent series usingcontinuous flow devices theincidence of RVF is between20 and 40%.

Evaluation of pre-operativerisk factors for post-operativeRHF.

Risk scoring systems:

Matthews’score

Fitzpatrick’s score

Drakos’ score

Curr Opin Cardiol 2013, 28:223–233

CARMATSynCardia TAH (ex Jarvik-7-CardioWest)

Abiomed AbioCor TAH

Total Artificial Heart

It is mostly used as a “bridge to transplant”. The indications are reserved forpatients waiting for a heart transplant for which any other type of assistance isexcluded.

Patients with different devices for DT

Prof. Francesco Santini Divisione e Cattedra di CardiochirurgiaUniversità degli Studi di Genovafrancesco.santini@unige.it

Find the appropriate time to discuss and evaluate preferences,compliance, prognosis, and medical options with your patients;

Periodical systematic “heart failure review” with HF-patientsshouldinclude discussion of current and potential therapies for bothanticipated and unanticipated events, in a multidisciplinary fashion;

Intercept HF progression, since a timely indication is the key tosuccess !