What Can the Surgeon Do to Avoid Heart Replacement?
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Transcript of What Can the Surgeon Do to Avoid Heart Replacement?
Paolo FerrazziRozzano 17 aprile 2009
Paolo FerrazziDipartimento Cardiovascolare
Ospedali Riuniti Bergamo
Ninth International SymposiumNinth International Symposium HEART FAILURE & Co.HEART FAILURE & Co.
Rozzano ,April 17, 2009Rozzano ,April 17, 2009
What Can the Surgeon Do to Avoid
Heart Replacement?
Paolo FerrazziRozzano 17 aprile 2009
DIABETES
ValvularDisease
HEART
FAILURE
SURGERY
Cardiomyopathies
DelayedPrimaryPTCA
MyocardialInfarction
Hypertension
End Stage HF(10%)
Paolo FerrazziRozzano 17 aprile 2009
HTx
344/yrs
VAD 30/yrs
Conventional Surgery n° ?
25.000 End Stage
250.000 Heart failure
60%11%
15%
14%
ISCHEMIC
HYPERTENSIVE
VALVULAR
IDIOPATIC
Surgical Treatment of Heart Failure in Italy
Paolo FerrazziRozzano 17 aprile 2009
ICM worse results then DCM!!!ICM worse results then DCM!!!
Heart Failure Surgical Options
Heart Transplant VAD (recovery, continuous flow) Mitral annuloplasty
Paolo FerrazziRozzano 17 aprile 2009
Sugical Treatment of Heart Failure
Substitutive Surgery– Transplantation: shortage of donors– VAD: cost, management,
complications
Reconstructive Surgery– SVR + CABG (STICH Results)– No basic research
Paolo FerrazziRozzano 17 aprile 2009
Paolo FerrazziRozzano 17 aprile 2009
STICH Results
Comparison CABG vs SVR + CABG instead of HTx vs SVR + CABG in a sub-class of patients– VO2max and right catheterization not available
In more experienced Centers: exclusion from randomization of patients with a strong indication to SVR
Regional differences in surgical results– SVR long tradition?
Inadeguate mean ESV reduction (-19%) in SVR patients
Personal Opinions
Paolo FerrazziRozzano 17 aprile 2009
Paolo FerrazziRozzano 17 aprile 2009
SVR & diastolic function
Animal study Clinical follow-up
Mathematical model
Post-op ECHO study
DIASTOLICFUNCTION
SYSTOLICFUNCTION
Systolic improvement is paid by some diastolic dysfunction
… presented for the first time in 2000!
Paolo FerrazziRozzano 17 aprile 2009
Passive Diastolic Function ….a black hole in echocardiography
Systolic Function Early Diastole Late Diastole
Fractional shortening
Vcf
Stress-corrected Vcf
Ejection fraction
Tei index
Strain and strain rate
TDI S-wave
E/A ratio
DT msec
IVRT msec
PV S/D ratio
TDI-E/E’
Paolo FerrazziRozzano 17 aprile 2009
Clinical ResearchSVR ….. thinking to diastolic function:
The “horseshoe repair”
Potential Advantages Horseshoe repair
Volume EqD Eccentricity index Stroke volume Late diastolic function
Ferrazzi, et al JTCVS 2008Ferrazzi, et al JTCVS 2008
Paolo FerrazziRozzano 17 aprile 2009
Apr 2005 - Dec 2008
n pts 34 Age (mean) 59.07±8.9Mitral repair 21 pts
(61%)Follow-up (mean) 16±10.3
moHosp. Mortality 2 pts
(5.8%)Fu mortality 2**1 pneumonia after 4 mo and 1 sudden death after 2
mo
SVR – “HORSESHOE REPAIR”
84.1±11.699.5±13.4Ø Longitudinale (mm)
0.000150.3±7.764.2±5.5Ø Equatoriale (mm)0.000196.8±29.3 (-44%)174.0±56.3VTSV sn (ml)
0.00011.3±0.53.0±0.2NYHA
P-valueFollow-upPreop
0.000140.0±8.227.1±5.7FE (%)
0.002
Paolo FerrazziRozzano 17 aprile 2009
Experimental Research The Endoventricular Elastic Devices
Restore the elasticity of the dilatated heart
Reduce left ventricle volume
Store wasted energy during the diastolic phase
Give the stored energy back during the sistolic phase
Ferrazzi, et al J Cardiovasc Med 2006Ferrazzi, et al J Cardiovasc Med 2006
Paolo FerrazziRozzano 17 aprile 2009
Paolo FerrazziRozzano 17 aprile 2009
COMPLEX PATHOPHYSIOLOGICAL MECHANISM OF FUNCTIONAL MITRAL
INCOMPETENCE
Ischemic Heart Failure
VALVE PAPILLARY MUSCLES LEFT VENTRICLE
Paolo FerrazziRozzano 17 aprile 2009
Paolo FerrazziRozzano 17 aprile 2009
Work in progress...
Paolo FerrazziRozzano 17 aprile 2009
Current Practice:One size fits all !
Cardiac surgery
Surgical Trial Personalized surgery
Paolo FerrazziRozzano 17 aprile 2009
HEART FAILURE
GENOMICS&
BIOLOGY
ANATOMY&
GEOMETRY
PHYSIOLOGY
BIOENGINEERING
Heart Failure: back to surgical research...